ABSTRACT
Objective:
to investigate what is the best anthropometric predictor of arterial hypertension among private school students.
Method:
this was a cross-sectional study with 286 students between the ages of 10 and 14 from two private schools in the city of Paranavaí, Paraná, Brazil. The following variables were analyzed: body mass index, waist circumference and blood pressure. Statistical analysis was conducted with Pearson’s partial correlation test and multivariate logistic regression, with p<0.05.
Results:
both anthropometric indicators displayed weak correlation with systolic and diastolic levels, with coeffi cients (r) ranging from 0.27 to 0.36 (p < 0.001). Multivariate analysis showed that the only anthropometric indicator associated with arterial hypertension was waist circumference (OR= 2.3; 95% CI: 1.1-4.5), regardless of age or gender.
Conclusion:
this age group, waist circumference appeared to be a better predictor for arterial hypertension than body mass index.
Key words:
Anthropometry; Arterial Pressure; Adolescent Health
RESUMO
Objetivo:
investigar qual o melhor preditor antropométrico de hipertensão arterial em alunos de escolas privadas.
Método:
estudo transversal, com amostra composta por 286 alunos com idade de 10 a 14 anos de duas escolas privadas de Paranavaí-Paraná. As variáveis analisadas foram: índice de massa corporal, circunferência de cintura e pressão arterial. Na análise estatística foram utilizados os testes de correlação parcial de Pearson e a regressão logística multivariada, considerando-se p<0,05.
Resultados:
os dois indicadores antropométricos demonstraram fracas correlações com os níveis sistólicos e diastólicos, com coeficientes (r) variando de 0,27 à 0,36 (p< 0,001). Na análise multivariada, o único indicador antropométrico associado ao risco de hipertensão arterial foi a circunferência de cintura (OR= 2,3; IC 95%: 1,1-4,5) independente da idade e gênero.
Conclusão:
nesta faixa etária, a circunferência de cintura parece ser melhor do que índice de massa corporal como preditor de hipertensão arterial.
Descritores:
Antropometria; Pressão Arterial; Saúde do Adolescente
RESUMEN
Objetivo:
investigar cuál es el mejor predictor antropométrico de la hipertensión arterial en los alumnos de escuelas particulares.
Métodos:
estudio transversal con muestra compuestas por 286 alumnos con edad de 10 a 14 años de dos escuelas privadas de Paranavaí-Paraná. Las variables analizadas fueron: índice de masa corporal, circunferencia de la cintura y la presión arterial sistólica y diastólica. En el análisis de estadísticas fueron utilizadas las pruebas de correlación parcial de pearson y regresión logística multivariada considerándose p<0.05.
Resultados:
los dos indicadores antropométricos han mostrado débiles correlaciones con los niveles sistólicos y diastólicos, con Coeficientes (r) variando de 0,27 a 0,36 (p<0,001). En el análisis multivariado el único indicador antropométrico asociado al riesgo de hipertensión arterial fue la circunferencia de la cintura (OR=2,3; IC 95%: 1,1- 4,5) independiente de la edad y el género.
Conclusión:
en este grupo de edad, la circunferencia de la cintura parece ser mejor de que el índice de masa corporal como predictor de la hipertensión arterial.
Palabras clave:
Antropometría; Presión Arterial; Salud del Adolescente
INTRODUCTION
Obesity has become a great global health problem over the last decades. Recent data
have demonstrated a substantial increase in overweight and obese children and
adolescents in the last twenty years. Increased food consumption and lack of physical
activity, factors associated with obesity, contribute to at least 300,000 deaths per
year in the United States(
11 Basiratnia M, Derakhshan D, Ajdari S, Saki F. Prevalence of childhood
obesity and hypertension in south of Iran. Iran J Kidney Dis [Internet]. 2013 Jul
[cited 2014 Jan 01];7(4):282-9. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/23880805
http://www.ncbi.nlm.nih.gov/pubmed/23880...
).
One of the main causes of death in the world among adults are cardiovascular
diseases, usually progressive and with their roots in the early years of life.
Childhood and adolescence are important phases in this process, as they are marked by
biological changes in the human body. Furthermore, adolescents begin to adopt
patterns and independent behaviors which influence the risks for such
diseases(
22 Tsioufis C, Kyvelou S, Tsiachris D, Tolis P, Hararis G, Koufakis N, et
al. Relation between physical activity and blood pressure levels in young Greek
adolescents: the Leontio Lyceum Study. Eur J Public Health [Internet]. 2011 Feb
[cited 2014 Jan 01];21(1):63-8. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/20142399 DOI:
10.1093/eurpub/ckq006
http://www.ncbi.nlm.nih.gov/pubmed/20142...
).
Among the numerous diseases of this type, one of the most prevalent among the general
population is systemic arterial hypertension, characterized by high and sustained
levels of blood pressure. Moreover, hypertension is no longer exclusive to adults, as
obese children and adolescents can potentially develop such altered
hemodynamics(
33 Reuter ÉM, Reuter CP, Burgos LT, Reckziegel MB, Nedel FB, Albuquerque
IM, et al. Obesity and arterial hypertension in schoolchildren from Santa Cruz do Sul
- RS, Brazil. Rev Assoc Med Bras [Internet]. 2012 Nov-Dec [cited 2014 Jan
01];58(6):666-72. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/23250094
http://www.ncbi.nlm.nih.gov/pubmed/23250...
).
It is known that alterations such as obesity and excessive central fat precede
increased blood pressure in children and adolescents. For this reason, researchers
have investigated the predictive capacity of anthropometric qualities, in the context
of using simple, practical and low-cost methods, to assess risk factors for
cardiovascular diseases among this age group(
44 Moser DC, Giuliano ICB, Titski ACK, Gaya AR, Coelho Silva MJ, Leite N.
Anthropometric measures and blood pressure. J Pediatr (Rio J) [Internet]. 2013
May-Jun [cited 2014 Jan 01];89(3):243-9. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/23684458 DOI:
10.1016/j.jped.2012.11.006
http://www.ncbi.nlm.nih.gov/pubmed/23684...
).
Detecting risk indicators among the youth population is essential for monitoring
individuals who present greater chances of developing altered blood pressure in
adulthood(
55 Araújo TL, Lopes MVO, Cavalcante TF, Guedes NG, Moreira RP, Chaves ES,
et al. [Analysis of risk indicators for the arterial hypertension in children and
teenagers]. Rev Esc Enferm USP [Internet]. 2008 Mar [cited 2014 Jan 01];42(1):120-6.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/18450156
Portuguese.
http://www.ncbi.nlm.nih.gov/pubmed/18450...
).
OBJECTIVE
This study aimed to investigate what is the best anthropometric predictor for arterial hypertension among private school students in the city of Paranavaí, Paraná, Brazil.
METHOD
This was a cross-sectional study conducted between July and August 2013. The sample consisted of students between the 6th and 9th grades, aged 10 to 14, at two private schools in Paranavaí, Paraná, Brazil. The classes were selected through systematized random allocation in two steps: 1) by using the lottery method, one class from each year from both schools were drawn; and 2) students from the selected classes were invited to participate and received an explanation on the nature of the study.
Sample size calculation was obtained by considering the total number of students in the studied population (n=417), an outcome prevalence of 50% (arterial hypertension) with a 95% confidence interval and 5% sampling error. Based on these parameters, we aimed to collect data from 200 students. Assessments were conducted only with students who agreed to participate in the study and who presented the Free and Informed Consent Form signed by their parents or legal guardians (n=298). Of these, 12 were excluded because: 1) they did not fall in the 10 to 14 age group; and 2) they did not participate in all the assessments. The final sample comprised 286 children and adolescents; 149 boys and 137 girls. The margin of sampling error calculated post hoc was 3.3% to 3.4%, a result below the level established a priori (5%).
The assessments were carried out during school hours by trained evaluators and with
calibrated instruments. Height was measured using a wall stadiometer (Wisoâ, Brazil)
with 0.1 cm resolution, and body mass with a digital scale (G-Tech) with 100-gram
resolution and 150 kg maximum capacity. Participants wore only their school uniform,
with or without objects in their pockets. Body mass index (kg/m2) was used to
categorize the students as eutrophic or overweight(
66 Conde WL, Monteiro CA. Body mass index cutoff points for evaluation of
nutritional status in Brazilian children and adolescents. J Pediatr (Rio J)
[Internet]. 2006 Jul-Aug [cited 2014 Jan 01];82(4):266-72. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/16858504
http://www.ncbi.nlm.nih.gov/pubmed/16858...
). Data from students with low weight (0.3%; n =1)
were included in the eutrophic category.
Waist circumference was measured using a flexible and non-elastic tape measure
(Gullikâ, Brazil), with 0.1 cm resolution, applied immediately above the iliac crest.
To classify abdominal obesity (central), we established P≥ 75° as the cutoff point
for all ethnicities(
77 Fernández JR, Redden DT, Pietrobelli A, Allison DB. Waist circumference
percentiles in nationally representative samples of African-American,
European-American, and Mexican-American children and adolescents. J Pediatr
[Internet]. 2004 Oct [cited 2014 Jan 01];145(4):439-44. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/15480363
http://www.ncbi.nlm.nih.gov/pubmed/15480...
).
Blood pressure was measured according to the techniques recommended by the Brazilian
Society of Cardiology(
88 Sociedade Brasileira de Cardiologia-SBC; Sociedade Brasileira de
Hipertensão-SBH; Sociedade Brasileira de Nefrologia-SBN. [V Brazilian Guidelines in
Arterial Hypertension]. Arq Bras Cardiol [Internet]. 2007 Sep [cited 2014 Jan
01];89(3):e24-79. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17906811
Portuguese.
http://www.ncbi.nlm.nih.gov/pubmed/17906...
), using a mercury sphygmomanometer (Wan Medâ, Brazil).
Measurements were collected at three points, with a minimum twominute interval
between them. For data analysis we used the mean value of the two last measurements.
Values of systolic or diastolic blood pressure equal to or greater than the 90º
percentile or 120 mmHg and/or 80 mmHg were considered high(
99 National High Blood Pressure Education Program Working Group on High
Blood Pressure in Children and Adolescents. The fourth report on the diagnosis,
evaluation, and treatment of high blood pressure in children and adolescents.
Pediatrics [Internet]. 2004 Aug [cited 2014 Jan 01];114(2 Suppl 4th Rep):555-76.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/15286277
http://www.ncbi.nlm.nih.gov/pubmed/15286...
).
For statistical analysis, the Kolmogorov-Smirnov test was used to identify the normality of the data and the existence of outliers was verified using box plots. Outliers were included in the analyses because they corresponded to data from overweight students, which were of interest to this study.
Student’s t-test was used to compare the anthropometric and hemodynamic characteristics between genders; Levene’s test was used to test for equality of variances between the investigated groups.
Pearson’s test for partial correlations was used to analyze the relation between body mass index (BMI) and waist circumference (WC), and of both measures with regards to systolic blood pressure (SBP) and diastolic blood pressure (DBP), adjusted for gender and age.
Exploratory data analysis demonstrated a non-linear relationship between x and y, from a determined point of its distribution, demonstrating a logistic S-curve. Thus, binomial multivariate regression was conducted to determine the odds ratio (OR) and the respective confidence intervals (95%) used to analyze the independent association between arterial hypertension (dependent variable) and BMI and WC (independent variables). All the studied variables were categorized, and inclusion criterion of the independent variables in the multivariate models was an association level of p ≤ 0.20 with the dependent variable, according to the chi-square test.
Analyses were conducted using the Statistical Package for the Social Sciences (SPSS) software, version 20.0, with p<0.05. The research proposal was approved by the research ethics committee of Maringá State University, under resolution number 353.552 and in accordance with the Declaration of Helsinki.
RESULTS
The mean values for BMI, height and WC were higher among boys than in girls (p≤0.05). In terms of age, mean BMI, SBP and DBP values were equal between the two groups (Table 1).
Age and anthropometric characteristics of private school students in Paranavaí, Paraná, Brazil, 2013
Table 2 presents an analysis of the relationship among the studied variables and shows that the anthropometric measurements presented weak correlations with SBP and DBP, with coefficients ranging between 0.27 and 0.36. However, two anthropometric indicators (BMI and WC) presented strong correlation (r=0.84 p<0.001), indicating collinearity between them.
Pearson’s partial correlation (r) for the studied variables adjusted for age and gender among private school students in Paranavaí, Paraná, Brazil, 2013
Multivariate analysis showed that the model with the greater predictive validity included BMI, WC, gender and age, (Hosmer and Lemeshow goodness of fit index for the model = 0.974), with the capacity of explaining 73.1% of adequate blood pressure cases. The only variable that was positively associated with higher blood pressure levels was waist circumference (p=0.020), indicating that students with measurements above the cutoff point (≥75°) were 2.3 more likely (130% greater chance) to present high blood pressure (95% CI: 1.1-4.5), when compared to those with adequate measurements. Gender, age and BMI were not associated with risk for high blood pressure (Table 3).
Odds Ratio for risk of high blood pressure adjusted for age and gender among private school students in Paranavaí, Paraná, Brazil, 2013
DISCUSSION
The frequency of high blood pressure among children and adolescents has increased
worldwide(
55 Araújo TL, Lopes MVO, Cavalcante TF, Guedes NG, Moreira RP, Chaves ES,
et al. [Analysis of risk indicators for the arterial hypertension in children and
teenagers]. Rev Esc Enferm USP [Internet]. 2008 Mar [cited 2014 Jan 01];42(1):120-6.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/18450156
Portuguese.
http://www.ncbi.nlm.nih.gov/pubmed/18450...
). In
particular, overweight individuals have presented higher proportions of hypertensive
measurements and cardiovascular risks(
1010 Carneiro G, Faria AN, Ribeiro Filho FF, Guimarães A, Lerário D, Ferreira
SR, et al. [Influence of body fat distribution on the prevalence of arterial
hypertension and other cardiovascular risk factors in obese patients]. Rev Assoc Med
Bras [Internet]. 2003 Jul-Sep [cited 2014 Jan 01];49(3):306-11. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/14666357 Portuguese.
http://www.ncbi.nlm.nih.gov/pubmed/14666...
-
1111 Kleiser C, Schienkiewitz A, Schaffrath Rosario A, Prinz-Langenohl R,
Scheidt-Nave C, Mensink GBM. Indicators of overweight and cardiovascular disease risk
factors among 11- to 17-year-old boys and girls in Germany. Obes Facts [Internet].
2011 [cited 2014 Jan 01];4(5):379-85. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/22166758 DOI: 10.1159/000333428
http://www.ncbi.nlm.nih.gov/pubmed/22166...
).
Studies have attempted to identify the best anthropometric indicator for high blood
pressure among children and adolescents, but the results have been
conflicting(
11 Basiratnia M, Derakhshan D, Ajdari S, Saki F. Prevalence of childhood
obesity and hypertension in south of Iran. Iran J Kidney Dis [Internet]. 2013 Jul
[cited 2014 Jan 01];7(4):282-9. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/23880805
http://www.ncbi.nlm.nih.gov/pubmed/23880...
,
44 Moser DC, Giuliano ICB, Titski ACK, Gaya AR, Coelho Silva MJ, Leite N.
Anthropometric measures and blood pressure. J Pediatr (Rio J) [Internet]. 2013
May-Jun [cited 2014 Jan 01];89(3):243-9. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/23684458 DOI:
10.1016/j.jped.2012.11.006
http://www.ncbi.nlm.nih.gov/pubmed/23684...
,
1212 Freedman DS, Katzmarzyk PT, Dietz WH, Srinivasan SR, Berenson GS.
Relation of body mass index and skinfold thicknesses to cardiovascular disease risk
factors in children : the Bogalusa Heart Study. Am J Clin Nutr [Internet]. 2009 Jul
[cited 2014 Jan 01];90(1):210-6. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/19420092 DOI:
10.3945/ajcn.2009.27525
http://www.ncbi.nlm.nih.gov/pubmed/19420...
–
1414 González Jiménez E, Aquilar Cordeiro MJ, García García CJ, García López
PA, Álvarez Ferré J, Padilha López CA. [Prevalence of nutritional overweight and
obesity and hypertension as well as their relationship with anthropometric indicators
in a population of students in Granada and its provinces]. Nutr Hosp [Internet]. 2011
Sep-Oct [cited 2014 Jan 01];26(5):1004-10. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/22072345 Spanish. DOI:
10.1590/S0212-16112011000500013
http://www.ncbi.nlm.nih.gov/pubmed/22072...
). The
present study aimed to highlight such divergences, analyzing the relationship between
blood pressure with two anthropometric indicators of obesity (BMI and WC), which are
easy to use among this population.
The results showed weak correlations between both anthropometric parameters and SBP
and DBP, a finding that corroborates those of previous studies(
44 Moser DC, Giuliano ICB, Titski ACK, Gaya AR, Coelho Silva MJ, Leite N.
Anthropometric measures and blood pressure. J Pediatr (Rio J) [Internet]. 2013
May-Jun [cited 2014 Jan 01];89(3):243-9. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/23684458 DOI:
10.1016/j.jped.2012.11.006
http://www.ncbi.nlm.nih.gov/pubmed/23684...
,
99 National High Blood Pressure Education Program Working Group on High
Blood Pressure in Children and Adolescents. The fourth report on the diagnosis,
evaluation, and treatment of high blood pressure in children and adolescents.
Pediatrics [Internet]. 2004 Aug [cited 2014 Jan 01];114(2 Suppl 4th Rep):555-76.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/15286277
http://www.ncbi.nlm.nih.gov/pubmed/15286...
). The magnitude of these correlations may have been
compromised due to the multifactorial characteristic of high blood pressure,
influenced by environmental factors or by the logistic behavior of the data. It is
worth noting that blood pressure measurements were taken at only one point (during
school hours), representing a possible classification bias and a limitation of this
study.
Another important finding was the positive association of waist circumference as an anthropometric indicator independently associated with arterial hypertension. The students classified with central obesity (P≥75°) were 130% more likely (OR=2.3) to have high blood pressure in comparison with students who were not diagnosed with abdominal obesity.
Some studies have pointed to obesity as a risk factor for increased blood pressure in
children and adolescents, however, the best anthropometric parameter is still
contradictory; some studies showed WC as the best predictor(
55 Araújo TL, Lopes MVO, Cavalcante TF, Guedes NG, Moreira RP, Chaves ES,
et al. [Analysis of risk indicators for the arterial hypertension in children and
teenagers]. Rev Esc Enferm USP [Internet]. 2008 Mar [cited 2014 Jan 01];42(1):120-6.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/18450156
Portuguese.
http://www.ncbi.nlm.nih.gov/pubmed/18450...
,
1515 Chuang SY, Pan WH. Predictability and implications of anthropometric
indices for metabolic abnormalities in children: nutrition and health survey in
Taiwan elementary children, 2001-2002. Asia Pac J Clin Nutr [Internet]. 2009 [cited
2014 Jan 01];18(2):272-9. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/19713188
http://www.ncbi.nlm.nih.gov/pubmed/19713...
), while others indicated BMI as having a higher association
among this age group(
1313 Queiroz VM, Moreira PVL, Vasconcelos THC, Vianna RPT. Prevalence and
anthropometric predictors of high blood pressure in schoolchildren from João Pessoa -
PB, Brazil. Arq Bras Cardiol [Internet]. 2010 [cited 2014 Jan 01];95(5):629-34.
Available from: http://www.scielo.br/pdf/abc/v95n5/en_v95n5a11.pdf
http://www.scielo.br/pdf/abc/v95n5/en_v9...
,
1616 Kuschnir MCC, Mendonça GA. Risk factors associated with arterial
hypertension in adolescents. J Pediatr (Rio J) [Internet]. 2007 Jul-Aug [cited 2014
Jan 01];83(4):335-42. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/17627321
http://www.ncbi.nlm.nih.gov/pubmed/17627...
). In
the present research, there was a strong correlation between BMI and WC (r=0.84;
p<0.001). This finding could explain the existing conflict in the literature, as
among this population, it is possible that high BMI values are directly related to
excess body fat. This is because the lean-fat proportion among this age group is not
very expressive, especially among prepubescents and pubescents. An analysis of the
students’ sexual maturation could have provided more details on the issue, but due to
bureaucratic problems and school procedures, we were not able to conduct such an
analysis.
The use of Brazilian criteria and cutoff points to classify BMI(
66 Conde WL, Monteiro CA. Body mass index cutoff points for evaluation of
nutritional status in Brazilian children and adolescents. J Pediatr (Rio J)
[Internet]. 2006 Jul-Aug [cited 2014 Jan 01];82(4):266-72. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/16858504
http://www.ncbi.nlm.nih.gov/pubmed/16858...
) conferred greater reliability to
analyses of this variable in this study, as they were more precise in determining
high blood pressure among boys and girls aged 10 to 17 in comparison to international
references(
1717 Christofaro DGD, Fernandes RA, Polito MD, Romanzini M, Ronque ERV, Gobbo
LA, et al. A comparison between overweight cutoff points for detection of high blood
pressure in adolescents. J Pediatr (Rio J) [Internet]. 2009 [cited 2014 Jan
01];85(4):353-8. Available from:
http://www.scielo.br/pdf/jped/v85n4/en_v85n4a14.pdf
http://www.scielo.br/pdf/jped/v85n4/en_v...
).
Notwithstanding, the lack of regression-based association between high blood pressure and BMI in the present study does not dismiss its importance in predicting arterial hypertension among children and adolescents, as it was correlated with systolic and diastolic levels. This finding suggests that it is a potential indicator of arterial hypertension. A possible explanation for such lack of association may be the period in which the students were exposed to excess weight, which was not enough to provoke hemodynamic alterations.
On the other hand, the association found between blood pressure and waist
circumference may have been negatively influenced, distorting the estimates of the
risk for high blood pressure, due to the use of international criteria. Such criteria
are not sensitive and specific enough to identify high blood pressure among Brazilian
children and adolescents due to the strong miscegenation of this population, which
requires specific critical values(
1818 Rosa MLG, Mesquita ET, Rocha ERR, Fonseca VM. Body mass index and waist
circumference as markers of arterial hypertension in adolescents Arq Bras Cardiol
[Internet]. 2004 [cited 2014 Jan 01];88(5):573-8. Available from:
http://www.scielo.br/pdf/abc/v88n5/en_a12v88n5.pdf
http://www.scielo.br/pdf/abc/v88n5/en_a1...
). In this sense, Brazilian cutoff points for this age group
must be validated in order to confer greater reliability to studies with
students.
CONCLUSIONS
Conducting appropriate routine blood pressure measurements at school is hindered by lack of adequate equipment and, in particular, lack of trained evaluators to perform the technique. Anthropometric indicators are simple and yet reliable options for hypertension risk stratification. In this research, waist circumference was the best predictor for high blood pressure among the students, regardless of BMI, gender and age. However, further studies with this population that include stages of puberty must be conducted, as different maturation classifications can interfere in data interpretation.
-
How to cite this article:
Guilherme FR, Molena-Fernandes CA, Guilherme VR, Fávero MTM, Reis EJB, Rinaldi W. Body mass index, waist circumference, and arterial hypertension in students. Rev Bras Enferm. 2015;68(2):210-4.
-
1Basiratnia M, Derakhshan D, Ajdari S, Saki F. Prevalence of childhood obesity and hypertension in south of Iran. Iran J Kidney Dis [Internet]. 2013 Jul [cited 2014 Jan 01];7(4):282-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23880805
» http://www.ncbi.nlm.nih.gov/pubmed/23880805 -
2Tsioufis C, Kyvelou S, Tsiachris D, Tolis P, Hararis G, Koufakis N, et al. Relation between physical activity and blood pressure levels in young Greek adolescents: the Leontio Lyceum Study. Eur J Public Health [Internet]. 2011 Feb [cited 2014 Jan 01];21(1):63-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20142399 DOI: 10.1093/eurpub/ckq006
» https://doi.org/10.1093/eurpub/ckq006» http://www.ncbi.nlm.nih.gov/pubmed/20142399 -
3Reuter ÉM, Reuter CP, Burgos LT, Reckziegel MB, Nedel FB, Albuquerque IM, et al. Obesity and arterial hypertension in schoolchildren from Santa Cruz do Sul - RS, Brazil. Rev Assoc Med Bras [Internet]. 2012 Nov-Dec [cited 2014 Jan 01];58(6):666-72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23250094
» http://www.ncbi.nlm.nih.gov/pubmed/23250094 -
4Moser DC, Giuliano ICB, Titski ACK, Gaya AR, Coelho Silva MJ, Leite N. Anthropometric measures and blood pressure. J Pediatr (Rio J) [Internet]. 2013 May-Jun [cited 2014 Jan 01];89(3):243-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23684458 DOI: 10.1016/j.jped.2012.11.006
» https://doi.org/10.1016/j.jped.2012.11.006» http://www.ncbi.nlm.nih.gov/pubmed/23684458 -
5Araújo TL, Lopes MVO, Cavalcante TF, Guedes NG, Moreira RP, Chaves ES, et al. [Analysis of risk indicators for the arterial hypertension in children and teenagers]. Rev Esc Enferm USP [Internet]. 2008 Mar [cited 2014 Jan 01];42(1):120-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18450156 Portuguese.
» http://www.ncbi.nlm.nih.gov/pubmed/18450156 -
6Conde WL, Monteiro CA. Body mass index cutoff points for evaluation of nutritional status in Brazilian children and adolescents. J Pediatr (Rio J) [Internet]. 2006 Jul-Aug [cited 2014 Jan 01];82(4):266-72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16858504
» http://www.ncbi.nlm.nih.gov/pubmed/16858504 -
7Fernández JR, Redden DT, Pietrobelli A, Allison DB. Waist circumference percentiles in nationally representative samples of African-American, European-American, and Mexican-American children and adolescents. J Pediatr [Internet]. 2004 Oct [cited 2014 Jan 01];145(4):439-44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15480363
» http://www.ncbi.nlm.nih.gov/pubmed/15480363 -
8Sociedade Brasileira de Cardiologia-SBC; Sociedade Brasileira de Hipertensão-SBH; Sociedade Brasileira de Nefrologia-SBN. [V Brazilian Guidelines in Arterial Hypertension]. Arq Bras Cardiol [Internet]. 2007 Sep [cited 2014 Jan 01];89(3):e24-79. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17906811 Portuguese.
» http://www.ncbi.nlm.nih.gov/pubmed/17906811 -
9National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics [Internet]. 2004 Aug [cited 2014 Jan 01];114(2 Suppl 4th Rep):555-76. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15286277
» http://www.ncbi.nlm.nih.gov/pubmed/15286277 -
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Publication Dates
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Publication in this collection
Mar-Apr 2015
History
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Received
12 Dec 2014 -
Accepted
11 Feb 2015