OBJETIVO: Comparar a pressão arterial, o perfil lipídico, o consumo alimentar e dados antropométricos em adolescentes com ou sem antecedente familiar de hipertensão arterial. MÉTODOS: Foram avaliados 43 adolescentes de ambos os sexos, na faixa etária entre 11 a 18 anos, sendo 20 filhos de hipertensos e 23 de normotensos e examinados: a pressão arterial, o consumo alimentar, dados antropométricos, o perfil lipídico e o resultado da orientação dietética (American Heart Association). RESULTADOS: Os filhos dos hipertensos mostraram maiores valores basais de pressão arterial sistólica (109 ± 3 vs. 99 ± 2 mm Hg, p=0,01) e diastólica (68 ± 2 vs. 62 ± 2 mm Hg, p=0,04), da relação CT/HDL-c (4,1 ± 0,3 vs. 3,2 ± 0,2, p<0.01) e de LDL-c/HDL-c (2,7 ± 0,2 vs. 1,9 ± 0,1, p<0,01) e menores valores de HDL-c (43 ± 2 vs. 53 ± 2 mg/dL, p<0,005). O consumo alimentar e medidas antropométricas analisadas não diferiram entre os grupos. A intervenção dietética, embora tenha resultado em reduções no índice de massa corpórea (21,0± 1,2 vs. 20,1 ± 1,1 kg/m², p<0,01), não modificou a dislipidemia presente nos filhos de hipertensos. CONCLUSÃO: Encontraram-se maiores níveis de pressão arterial e perfil lipídico mais desfavorável entre filhos de hipertensos, onde os níveis baixos de HDL-c foram o achado mais relevante e independente de variáveis antropométricas ou nutricionais.
adolescência; pressão arterial; hábitos alimentares; lipídios
OBJECTIVE: To compare blood pressure, lipid profile, food intake, and anthropometric data of adolescents with or without a familial history of hypertension. METHODS: Forty-three adolescents from both sexes were assessed, with ages ranging from 11 to 18 years old. Twenty had hypertensive parents, and 23 had normotensive parents. The following variables were examined: blood pressure, food intake, anthropometric data, lipid profile, and the results of following dietary guidelines (American Heart Association). RESULTS: The offspring of hypertensive parents had greater baseline systolic blood pressure (109 ± 3 vs. 99 ± 2 mm Hg, P=0.01), diastolic blood pressure (68 ± 2 vs. 62 ± 2 mm Hg, p=0.04), greater TC/HDL-C ratio (4.1 ± 0.3 vs. 3.2 ± 0.2, P<0.01), and greater LDL/HDL-C (2.7 ± 0.2 vs. 1.9 ± 0.1, P<0.01), and smaller values of HDL-C (43 ± 2 vs.53 ± 2 mg/dL, P<0.005). Dietary intake and anthropometric measures assessed did not differ between the groups. Even though dietary intervention resulted in reductions in body mass index (21.0± 1.2 vs. 20.1 ± 1.1 kg/m², P<0.01), it did not change dyslipidemia present in the offspring of hypertensive individuals. CONCLUSION: Increased blood pressure levels and less favorable lipid profiles are found among offspring of hypertensive parents, where low levels of HDL-C were the most relevant finding regardless of anthropometric or nutritional variables.
adolescence; blood pressure; dietary habits; lipids
Comparison of the lipid profile, blood pressure, and dietary habits of adolescents and children descended from hypertensive and normotensive individuals
Maria Cristina Elias; Max Samuel Mattos Bolívar; Francisco Antonio Helfenstein Fonseca; Tania Leme da Rocha Martinez; Japy Angelini; Celso Ferreira; Nelson Kasinski; Angelo Amato Vincenzo de Paola; Antonio Carlos Camargo Carvalho
Escola Paulista de Medicina - UNIFESP - São Paulo, SP - Brazil
OBJECTIVE: To compare blood pressure, lipid profile, food intake, and anthropometric data of adolescents with or without a familial history of hypertension.
METHODS: Forty-three adolescents from both sexes were assessed, with ages ranging from 11 to 18 years old. Twenty had hypertensive parents, and 23 had normotensive parents. The following variables were examined: blood pressure, food intake, anthropometric data, lipid profile, and the results of following dietary guidelines (American Heart Association).
RESULTS: The offspring of hypertensive parents had greater baseline systolic blood pressure (109 ± 3 vs. 99 ± 2 mm Hg, P=0.01), diastolic blood pressure (68 ± 2 vs. 62 ± 2 mm Hg, p=0.04), greater TC/HDL-C ratio (4.1 ± 0.3 vs. 3.2 ± 0.2, P<0.01), and greater LDL/HDL-C (2.7 ± 0.2 vs. 1.9 ± 0.1, P<0.01), and smaller values of HDL-C (43 ± 2 vs.53 ± 2 mg/dL, P<0.005). Dietary intake and anthropometric measures assessed did not differ between the groups. Even though dietary intervention resulted in reductions in body mass index (21.0± 1.2 vs. 20.1 ± 1.1 kg/m2, P<0.01), it did not change dyslipidemia present in the offspring of hypertensive individuals.
CONCLUSION: Increased blood pressure levels and less favorable lipid profiles are found among offspring of hypertensive parents, where low levels of HDL-C were the most relevant finding regardless of anthropometric or nutritional variables.
Key words: adolescence, blood pressure, dietary habits, lipids
Despite greater emphasis in the adult population on the correlation between blood pressure and coronary artery disease, and strokes and renal disorders, blood pressure values during childhood seem to be associated with hypertension at a more advanced age 1.
The prevalence of systemic blood hypertension in children and adolescents is estimated at 6 to 8%, respectively 2.
Considering these facts, it is important that adolescents are guided towards the prevention of risk factors, such as obesity, excessive salt intake, and lack of exercise that seems to be associated with the increase in blood pressure values and aging 3.
Additionally, an unfavorable lipid profile and an increase in blood pressure, especially in association with other risk factors, are, according to the World Health Organization (WHO)4, conditions that favor the greater development of atherosclerosis during childhood.
Epidemiologic studies have demonstrated that hypertensive patients have unfavorable lipid profiles more frequently than does the general population 5-7. In the Tromso6 study, a biological intercorrelation between blood pressure and lipids seemed to be associated with coronary artery disease.
Diet may play an essential role in the prevention of systemic blood hypertension 8. Poor dietary habits, such as a high intake of food rich in saturated fat, cholesterol, and salt in association with the lack of exercise, have been related to several chronic diseases, especially hypertension, hyperlipidemia, and diabetes mellitus, conditions frequently associated in adult life 9-11.
Based on the early beginning of atherosclerosis in children and adolescents, and due to the increased importance of blood hypertension and its correlation with dyslipidemia in coronary disease in adults, this study aimed at verifying blood pressure and assessing lipid alterations in this population. The study also examined possible changes in lipid profile through a controlled dietary intervention.
The research was approved by the Ethics Committee for Research at the Federal University of São Paulo/Paulista School of Medicine and started after written consent was obtained from one parent.
Twenty adolescents with hypertensive parents 2 of both sexes and ages ranging from 11 to 18 years old were assessed, followed-up in the Cardiology Department wards. The control group comprised 23 volunteers with normotensive parents. Those who had at least 1 hypertensive parent were considered offspring of hypertensive parents, and all subjects were assessed according to age, sex, and level of sexual maturation according to Tanner' s criteria 12 (tab. I). Parents of adolescents had their blood pressure assessed (data not presented) to classify the 2 groups: offspring of hypertensive parents and offspring of normotensive parents.
Adolescents had their lipid profile determined after 12 to 14 hours of fasting, by using the color metric enzyme method. LDL-C was estimated using the Friedewald formula 13. All the analyses were performed with the Opera machine (Bayer, Germany).
Blind determination of blood pressure was performed, using a mercury column sphygmomanometers, in the Cardiology Department with the patient in a seated position, with 2 measures after 5 minutes, and 1- to 2-minute intervals between them 2.
The tables of percentiles for boys and girls with ages ranging from 10 to 17 years old from the Second Task Force on Blood Pressure Control in Children, 1987 14 was used as a reference for the analysis of results. Dietary habits were assessed through the frequency of food, 24-hour diet diary, and a 3-day dietary journal, with the participation of parents. Based on these data, on anthropometric measures, and on laboratory examinations, customized nutritional guidance was created for the adolescents, monitored every month for a 16-week period.
For calculation and elaboration of the nutritional guidelines, the following programs to support blood pressure were used: CIS-EPM/UNIFESP and the virtual nutriUSP 15,16.
Nutritional guidelines were elaborated based on dietary recommendations (DRs), for the macro and micro nutrients according to the age group studied, in addition to the recommendation of the American Heart Association (AHA, phase I) when the presence of dyslipidemia was detected 3.
Weight, height, body mass index, skinfold measurements (triceps, subscapular), and abdominal circumference were obtained (tab. I).
Body mass index values obtained were assessed in percentiles according to the criteria established by Sichieri and Allam 17, for the age group from 10 to 17 years and 11 months old, and for adolescents above this age, according to the American survey National Health and Nutrition Examination Survey (NHANES I) 18.
Percentiles related to the skinfold measurements were assessed according to the American survey NHANES I and the waist circumference according to Freedman et al criteria 19.
Data were expressed as mean ± SD. For the comparison of continuous variables, the nonpaired Student t test was used, and the paired test was used for the dietary intervention examination. Homogeneity of the groups was examined by the chi-square test. Level of rejection of the null hypothesis was fixed at 5%.
Systolic blood pressure (SBP) and diastolic blood pressure (DBP) values obtained were greater in offspring of hypertensive parents than in those of normotensive parents, although they were within the normal percentile for the age (tab. I). Differences between the groups regarding skinfold (triceps and subscapular), abdominal circumference, as well as for body mass index obtained did not occur, but decrease in this parameter was noted after nutritional intervention (tab. II).
Although differences between the dietary intake of the adolescents in the baseline period was not observed (tab. III), lower total caloric value and a tendency to increase the consumption of monounsaturated fat and a reduction in saturated fat were obtained after dietary guidance (tab. II).
Figure 1 shows that offspring of hypertensive parents had lower baseline HDL-C values (43 ± 2 vs. 53 ± 2 mg/dL, P<0.005), and greater TC/HDL-C indexes (4.1 ± 0.2 vs. 3.2 ± 0.2, P<0.001) and LDL-C/HDL-C (2.7 ± 0.2 vs. 1.9 ± 0.1, P<0.001) in comparison to offspring of normotensive parents. These populations did not differ regarding total cholesterol (168 ± 8 vs. 166 ± 5 mg/dL, ns) and LDL-C (108 ± 8 vs. 97 ± 5 mg/dL, ns) obtained at baseline. After dietary guidance, restricted to offspring of hypertensive parents with dyslipidemia, changes were not observed in comparison to the new lipid profile obtained (tab. II).
Our study identified, among offspring of hypertensive parents, higher blood pressure levels and a more unfavorable lipid profile (reduction in HDL-C and in the ratio TC/HDL-C and LDL-C/HDL-C) when compared with offspring of normotensive parents. Considering that all of these factors were associated with a greater development of atherosclerosis in children and adolescents in the anatomopathologic studies of Bogalusa 20 and PDAY 21, primary prevention of cardiovascular disease is suggested. Although the age group studied had normal blood pressure values, the observation that offspring of hypertensive parents had higher systolic and diastolic blood pressure values compared with those in the control group of adolescents, also suggests that values currently considered normal for these youngsters may be revised in the future, enabling, at least, the identification of a population with a greater probability of developing hypertension and atherosclerosis in adult life. However, broad prospective studies, in the modern view of hypertension and atherosclerosis, are necessary to create new diagnostic criteria. In fact, those who are younger should be identified early, regarding their cardiovascular risk, to introduce more effective prevention.
A weak correlation for blood pressure between couples and between parents and adopted children has been demonstrated, which agrees with our findings. But this correlation index is increased between parents and consanguineous children, even though they have the same habits, suggesting a strong genetic influence in the pattern of blood pressure 22-25.
In our study, lower values of HDL-C were observed between the offspring of hypertensive patients, despite the similar body mass index and dietary habits in the intake of monounsaturated, polyunsaturated, and saturated fat, as well as carbohydrates and proteins.
Giannini et al 7 observed a higher frequency of dyslipidemia among relatives of hypertensive individuals, with lower HDL-C values among other abnormalities. Additionally, similar results were reported in the Tronso study 6 where hypertensive individuals had increased values of cholesterol and triglycerides, as well as lower HDL-C values. In another epidemiologic study 26, hypertensive individuals had dyslipidemia more frequently than did normotensive individuals, with a correlation between hypertension and hypercholesterolemia, regardless of other variables, such as age and body mass index.
The importance of HDL-C as an early marker of metabolic alterations in this group of adolescents of hypertensive parents seems to be established by these several studies and may represent one of the mechanisms to accelerate atherosclerosis in hypertension, by impairment in cholesterol transport.
Regarding dietary habits, we have observed that adolescents from both groups have similar diets, with an intake of food rich in cholesterol, saturated fat, and sodium, greater than those recommended by the III Brazilian Consensus of Blood Hypertension 2, and with low-fiber intake in disagreement with the recommendations for cardiovascular prevention in this age group 27-32.
To conclude, our study identified an unfavorable risk profile among the children of hypertensive parents. New criteria in cardiovascular risk stratification in children and adolescents with greater sensitivity for identifying abnormal pressure and lipid parameters seem relevant. In this context, greater emphasis on the control of risk factors, encouragement of physical activity, as well as the correction of dietary habits from childhood, customized in those with greater risk, may reduce or delay cardiovascular events in adult life.
- 1. Lauer R M, Clarke W R. Use of cholesterol measurements in childhood for prediction of adult hypercholesterolemia. JAMA 1991;264:3034-8.
- 2. III Consenso Brasileiro de Hipertensão Arterial. Rev Bras Clin Terap 1998;24: 231-72.
- 3. Strong WB, Deckelbaum RJ, Gidding SS, et al. Integrated cardiovascular health promotion in childhood: a statement for health professionals from the subcommittee on atherosclerosis and hypertension in childhood of the council on cardiovascular disease in the young, American Heart Association. Circulation, 1991;85:638-50.
- 4. Armstrong N, Balding J, Gentle P, Kirby B. Serum lipids and blood pressure in relation to age and sexual maturity. Ann Hum Biol 1992;19:477-87.
- 5. Williams RR, Hunt SC, Hopkins PN, Stults BM et al. Familial dyslipidemic hypertension: evidence from 58 Utah families for a syndrome present in approximately 12% of patients with essential hypertension. JAMA 1988;259:3579-86.
- 6. Bonna KH, Thelle DS. Association between blood pressure and serum lipids in a population - the Tronso Study. Circulation 1991;83:1305-14.
- 7. Giannini SD, Diament J, Forti N, et al. First-degree kinship with young coronary artery disease patients markedly increase lipid level disorders in asymptomatic hypertensive. J Cardiovasc Risk 1998;5:141-5.
- 8. Slater EE, Dustan HP, Grimm RH, et al. Metabolic and nutritional factors in hypertension. Hypertension 1991;18:I121-5.
- 9. Walter HJ, Hofman A, Connelly PA, Barrett LT, Kost KL. Primary prevention of chronic disease in childhhod chances in risk factors after year of intervention. Am J Epidemiol 1985;122:772-81.
- 10. McGill HC, Mott GE, Lewis DS, McMahan CA, Jackson EM. Early determinants of adult metabolic regulation effects of infant nutrition on adult lipid and lipoprotein metabolism. Nutr Rev 1996;54:S31-40.
- 11. Wilson DK, Klesges LM, Klesges RC. A prospective sudy of familial aggregation of blood pressure in young children. J Clin Epidemiol 1992;45:950-69.
- 12. Matsudo SMM, Matsudo VKR. Self-assessment and physican assessment of sexual maturation in brazilian boys and girls: concordance and reproducibility. Am J Hum Biol 1994:451-5.
- 13. Friedewald WT, Levy RI, Friedrickson DS. Estimation of the concentration of low density lipoprotein cholesterol in plasma without use of the preparative ultracentrifuge. Clin Chem 1972;18:499-502.
- 14. Task force report on high blood pressure in children and adolescents. 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 program. Pediatrics 1996;98:649-58.
- 15. Anção NS, Cuppari L, Tudisco ES, Draibe SA, Sigulen D. Sistema de apoio a decisão em Nutrição - versão 2,5- Centro de informática em saúde - CIS - Universidade Federal de São Paulo (UNIFESP/EPM) 1995.
- 16. Philippi ST, Szarfarc SC, Latterza AR. Virtual nutri (software), versão 1.0 for windows. Departamento de nutrição/ Faculdade de Saúde Pública/USP. São Paulo,1996.
- 17. Sichieri R, Allam VLC. Avaliação do estado nutricional de adolescentes brasileiros através do índice de massa corporal. J Pediatr 1996; 2 80-4.
18World Health Organization. Physical Status: The use and interpretation of anthropometry. Geneva. WHO Expert Comitee 1995;445-9.
- 19. Freedman DS, Serdula MK, Srinivasan SR, Berenson GS. Relation of circumference and skinfold thicknesses to lipid and insulin concentrations in children and adolescents: The Bogalusa Heart Study. Am J Clin Nutr 1999;69:308-17.
- 20. Freedman DS, Srinivasan SR, Shear CL, Webber LS, Chiang YK, Berenson GS. Correlates of high density lipoprotein cholesterol and apolipoprotein A-l levels in children. The Bogalusa Heart Study.Arteriosclerosis. 1987;7:354-60.
- 21. Zieske AW, Malcom GT, Strong JP. Natural history and risk factors of atherosclerosis in children and youth: the PDAY Study. Pediatr Pathol Mol Med. 2002; 21:213-37.
- 22. Kaplan NM. Clinical Hypertension, 5 th ed. Maryland: Williams & Wilkins 1990:p55.
- 23. Cavalcante JWS, Cavalcante LP, Pacheco WS, Menezes MGF, Gama F° CG. Comportamento da pressão arterial em filhos de normotensos e filhos de hipertensos submetidos a estímulos pressóricos. Arq Bras Cardiol 1997;69:323-6.
- 24. Rotimi CN,Cooper RS, Cao G, Ogunbiyi O, Ladipo M, Owoaje E, Ward R Maximum-likelihood generalized heritability estimate for blood pressure in Nigerian families. Hipertension 1999;33:874-8.
- 25. Williams RR, Hunt SC, Hasstedt SJ, et al. Are there interactions and relations between genetic and environmental factors predisposing to high blood pressure? Hypertension 1991;18:I29-37.
- 26. Goode GK, Miller JP, Heagerty AM. Hyperlipidaemia, hypertension,and coronary heart disease. Lancet 1995;345:363-4.
- 27. Monge-Rojas R. Dietary intake as a cardiovascular risk factor in Costa Rican adolescents. J Adolesc Health 2001;28:328-37.
- 28. Kersting M, Sichert-Hellert W, Alexy U, Manz F, Schüch G. Macronutrient intake of 1 to 18 year old German children and adolescents. Z Ernahrungswiss 1998:37:252-9.
- 29. NCEP expert panel on blood cholesterol levels in children and adolescents. National Cholesterol Education Program (NCEP): High lights of the report of the expert panel on blood cholesterol in children and adolescents. Pediatrics 1992;89:495-501.
- 30. Kwiterovich PO. The role of fiber in the treatment of hypercholesterolemia in children and adolescents. Pediatrics 1995;96:1005-9.
- 31. Sanches-Bayle M, Gonzales-Requejo A, Baeza J, et al. Diet therapy for hypercholesterolemia in children and adolescents. Arch Pediatr Adolesc Med 1994;148:28-32.
- 32. Strong JP, Malcon GT, Mcmahan CA, et al. Prevalence and extent of atherosclerosis in adolescents and young adults: implications for prevention from the pathobiological determinants of atherosclerosis in youth study. JAMA 1999;281:727-35.
- 33. DISC Collaborative Research Group. Efficacy and safety of lowering dietary intake of fat and cholesterol in children with elevated low-density lipoprotein cholesterol. JAMA 1995;273:1429-35.
- 34. Vizcaíno VM, Aguilar FS, Gutiérrez RF, Crespo YJ, Navalón PG, Rojas VD. Familial aggregation of cardiovascular disease risk factors: the Cuenca Study. Preventive Medicine 1999;28:131-37.
- 35. Vizcaíno VM, Aquilar FS, Gutiérrez RF, Crespo YJ, Navalón PG, Rojas VD. Familial aggregation of cardiovascular disease risk factors: the Cuenca Study. Preventive Medicine 1999; 28:131-7.
- 36. Kotchen TA, Kotchen JM, Boegehold MA. Nutrition and hypertension prevention. Hypertension 1991;18:I115-20.
- 37. Lauer RM, Clarke WR. Childhood risk factors for high adult blood pressure: The Muscatine Study. Pediatrics 1989;84:633-41.
- 38. Law M. Dietary fat and adult diseases and the implications for chidhood nutrition: an epidemiologic approach. Am J Clin Nutr 2000;72 (suppl):1291-6.
Correspondence toFrancisco Helfenstein FonsecaSetor de Lípides, Aterosclerose e Biologia Vascular - UNIFESPRua Pedro de Toledo, 458Cep 04039-001 - São Paulo, SP - BrazilE-mail:
Publication in this collection
16 Mar 2004
Date of issue
19 Nov 2002
31 Mar 2003