The present study demonstrated that the prevalence of high blood pressure in adolescents aged 10-19 years in Thailand was 9.4% based on the cutoff values from the year 2017 guidelines by the AAP (1). BMI z-score was independently associated with hypertension in a dose-response relationship in both genders. Moreover, an average sleep duration < 6 hours/day was an independent factor associated with high blood pressure after adjusting for BMI z-score and lipid profile.
This is the first study to represent the national prevalence of high blood pressure in Thai adolescents. Compared to the previous national studies conducted before the year 2017 from Iran, Australia and China which reported the prevalence at 6.8%, 5.8% and 6%, respectively (17–19), the prevalence of high blood pressure in the present study was higher. This finding could be partly explained by the fact that the cutoff values for diagnosis of hypertension of the year 2017 AAP guidelines used in the present study were lower than those of the year 2004 AAP guidelines (20) used in the studies from those countries. The year 2017 normative blood pressure tables were derived from the year 2004 normative blood pressure tables that did not include children and adolescents with overweight and obesity. Therefore, the cutoff values in the year 2017 guidelines were 2-3 mmHg lower than those of the year 2004 normative tables. The increase in the prevalence of hypertension by using these new cutoff values had been reported in an international cohort and a study from Thailand (21, 22). The prevalence of high blood pressure increased from 7–16.2% and 6.9 to 10.8% in the international cohort and Thai studies, respectively.
The present study showed that, in male participants, TC, LDL-C and TG levels were significantly higher and HDL-C levels were significantly lower in the high blood pressure group than the normotensive group. In female participants, TG levels were significantly higher and HDL-C levels were significantly lower in the high blood pressure group than in the normotensive group. These results were consistent with the study reported by Garí-Llanes M et al (23). Among 373 children aged 8-11 years in Cuba, the high blood pressure group had higher levels of TC, LDL-C, TG and lower levels of HDL-C than those in the normotensive group (23). In the present study, the higher BMI and more proportion of obesity in the high blood pressure group could explain why they had higher levels of TC, LDL-C and TG and lower levels of HDL-C than those in the normotensive group. In contrast, the other reports from Serbia and Italy did not show a significant difference in those lipid profiles between high blood pressure and normotensive children (24, 25). Since BMI and lipid profile in children and adolescents are correlated (26), the comparable BMI between the high blood pressure and normotensive groups in those reports from Italy and Serbia may explain the reason why there was no difference in lipid profiles between the two groups.
Apart from the BMI z-score and lipid profile, a sleep duration was found to be another independent factor associated with high blood pressure in male participants. The increases in sympathetic activity and appetite hormones such as ghrelin in individuals with short sleep duration were proposed to be the mechanisms underlying the association between sleep duration and blood pressure (27). There have been many studies reporting the association between sleep duration and blood pressure. Wells JCK et al found that short sleep duration was associated with increased systolic blood pressure for both genders in 4452 Brazilian adolescents aged 10-12 years (9). Bal C et al reported a study of 2860 Turkish adolescents aged 11-17 years and found that each hour of increase in sleep duration decreased the risk of hypertension by 12% (10). The effect of an increase in sleep duration on a decrease in the risk of high blood pressure seemed to exist for both genders. For the whole population, compared to the group with average sleep duration of > 8 hours/day (group C), an average sleep duration < 6 hours/day (group A) increased the risk of high blood pressure by 2-fold after adjusting for BMI z-score and lipid profile. This result was concordant with the data from Korea.(11)
When analyzing the data between male participants with overweight or obesity and the sleep duration on weekdays, the risk of high blood pressure in group A was even greater (8-fold) compared with that in group C. Nonetheless, the effect of short sleep duration on high blood pressure was attenuated in the male participants with BMI z-score <1. This finding enlightened the fact that short sleep duration increased the risk of high blood pressure particularly in male adolescents with overweight or obesity. The author also did not observe the associations of short sleep duration and high blood pressure in females. This could be due to a small number of female participants with high blood pressure compared to the number in males.
The present study represented the first national prevalence of high blood pressure in Thai adolescents. This study also demonstrated that not only BMI z-score but also was a sleep duration associated with high blood pressure after adjusting for the other parameters. However, this study has some limitations. Firstly, the cause and effect between the risk factors and high blood pressure could not be drawn from this cross-sectional survey. Secondly, high blood pressure was diagnosed based on just a single visit of BP measurement, not three occasions as recommended by the current guidelines, therefore the diagnosis of hypertension could not be made from this study. The data regarding awareness of hypertension and co-morbidities among these participants were not available. Moreover, the sleep duration was not measured using a validated self-reported tool specifically designed to measure adolescents’ sleep such as the Adolescent Sleep-Wake Scale (28). Lastly, the number of female participants with high blood pressure was limited, so it might not have enough power to detect any significant association with the sleep duration. Therefore, the more researches on the association of sleep duration and risk of high blood pressure in adolescents are needed.