921 Normal-Weight, Overweight Or Obese Children and Adolescents Living in Central Europe
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International Journal of Obesity (2015) 39, 45–51 © 2015 Macmillan Publishers Limited All rights reserved 0307-0565/15 www.nature.com/ijo PEDIATRIC ORIGINAL ARTICLE Ethnicity and cardiovascular risk factors: evaluation of 40 921 normal-weight, overweight or obese children and adolescents living in Central Europe L Martin1, J Oepen2, T Reinehr3, M Wabitsch4, G Claussnitzer5, E Waldeck6, S Ingrisch7, R Stachow8, M Oelert9, S Wiegand1,11 and R Holl10,11 on behalf of the APV Study Group and the German Competence Network Adipositas12 BACKGROUND AND AIMS: Cardiovascular disease (CVD) is a major global health problem and the leading cause of death in Europe. Risk factors such as obesity and hypertension that accelerate the development of CVD begin in childhood. Ethnicity is a known risk factor for CVD in adults. The aim of this study is to explore differences in the prevalence of hypertension and dyslipidemia among overweight/obese and normal-weight children/adolescents of three different ethnic origins living in Central Europe. METHODS AND PROCEDURES: Prevalence of hypertension and dyslipidemia was calculated among obese/overweight children/ adolescents (n = 25 986; mean age 12.7 ± 3.0 years; range: 0–18 years; 46% males) documented in the German-Austrian-Swiss APV (Prospective Documentation of Overweight Children and Adolescents) registry and among normal-weight subjects (n = 14 935; mean age: 8.8 ± 5.1years; range 0–18 years; 51% males) from the population-based cross-sectional German Health Interview and Examination Survey for Children and Adolescents (KiGGS) study. In both cohorts, subjects were categorized into three ethnic groups (Central European: Germany, Austria, Switzerland; Southeastern European: Turkish; Southern European: Spain, Portugal, Italy, Greece, Cyprus, Malta) based on the country of birth of both parents. Regression models were used to examine ethnic differences after adjustment for age and gender and body mass index (BMI) category. RESULTS: Age-, gender- and BMI category-adjusted prevalence of hypertension were 38% and 39% for the ethnic minority groups, compared with 35% among German/Austrian/Swiss counterparts. Turkish ethnicity was significantly associated with hypertension (odds ratio (OR) 1.14; 95% confidence interval: 1.02–1.27; P = 0.0446). No significant ethnic differences were found in lipid levels. Prevalence of hypertension found among normal-weight subjects (Central European vs Southeastern vs Southern European: 6.8% vs 6.3% vs 7.2%) did not differ significantly. CONCLUSIONS: Turkish obese/overweight children/adolescents showed a significantly higher prevalence of hypertension relative to their peers of Central European descent. No significant ethnic difference in the prevalence of hypertension was found among normal-weight children/adolescents. The high prevalence of hypertension among Turkish obese/overweight children/adolescents indicates the need for greater preventive and therapeutic efforts to reduce cardiovascular risk factors among vulnerable populations. International Journal of Obesity (2015) 39, 45–51; doi:10.1038/ijo.2014.167 INTRODUCTION adulthood,4,5 CVDs increasingly have their roots already in early In Europe, and globally, the most common cause of mortality is childhood. non-communicable diseases. Among non-communicable diseases, CVDs and its risk factors affect every ethnic group, but 6 cardiovascular diseases (CVDs) constitute the largest share.1 High inequalities exist among ethnic minority groups. A systematic blood pressure (BP), as a modifiable cardiovascular risk factor, has review on CVD risk among adult Turkish and Moroccan migrant been identified as the leading risk factor for global disease groups living in Europe has shown that obesity and diabetes are burden.2 Giving the increasing prevalence of pediatric obesity,3 more prevalent among migrant groups than among native Central which is frequently accompanied by several other cardiovascular European individuals.7 With regard to obesity prevalence, a similar risk factors, such as hypertension and dyslipidemia, and the pattern was found for youths living in Germany. The population- knowledge that those risk factors can be tracked into based representative survey German Health Interview and 1Department of Pediatric Endocrinology and Diabetology, Charité Children's Hospital, Charité University Medicine, Berlin, Germany; 2Viktoriastift Bad Kreuznach, Rehabilitation Clinic for Children and Adolescents, Bad Kreuznach, Germany; 3Vestische Children's Hospital, University of Witten/Herdecke, Datteln, Germany; 4Divison of Pediatric Endocrinology, Diabetes and Obesity Unit, University Children's Hospital, University of Ulm, Ulm, Germany; 5Spessart-Klinik, Rehabilitation Clinic for Children and Adolescents, Bad Orb, Germany; 6Edelsteinklinik, Rehabilitation Clinic for Children and Adolescents, Bruchweiler, Germany; 7Fachklinik Gaißach, Rehabilitation Clinic, Gaißach, Germany; 8Fachklinik Sylt, Rehabilitation Clinic for Children and Adolescents, Westerland, Germany; 9Katholisches Kinderkrankenhaus Wilhelmstift, Wilhelmstift Catholic Children's Hospital, Hamburg, Germany and 10Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany. Correspondence: Dr S Wiegand, Department of Pediatric Endocrinology and Diabetology, Charité Children's Hospital, Charité University Medicine Berlin, Augustenburger Platz 1, Berlin 13353, Germany. E-mail: [email protected] 11These authors contributed equally to this work. 12List of participating centers are listed before references. Received 24 March 2014; revised 9 August 2014; accepted 2 September 2014; accepted article preview online 12 September 2014; advance online publication, 7 October 2014 Cardiovascular risk in multiethnic pediatric cohorts L Martin et al 46 Examination Survey for Children and Adolescents (KiGGS) as well anthropometric parameters were documented routinely in specialized as preschool data collected by the German federal states have obesity centers according to the standardized specifications of the German indicated that 11- to 13-year-old children from migrant families Working Group of Childhood Obesity (AGA),19 as described previously.15 For the KiGGS study, a detailed description of data collection has been had an obesity prevalence of 10.0% compared with 6.4% among 20 their German peers.8,9 Similar results were found by Fredriks described previously. In both cohorts, BP was measured under et al.10 in a cohort of children of different ethnic backgrounds standardized conditions according to the guidelines of the German Hypertension League (Deutsche Hochdruckliga).21,22 Serum lipids were living in the Netherlands. Apart from childhood obesity, in Europe analyzed according to the guidelines of the Federal Chamber of there, in particular, is a shortage of information on the prevalence Physicians23 in accredited local laboratories (APV study) and centrally in of cardiovascular risk factors among children/adolescents of the laboratory of the German Herzzentrum Berlin (KiGGS study).24 In the ethnic minority groups. The existing studies have only been KiGGS study, non- fasting blood samples were collected.24 carried out among relatively small numbers of pediatric patients. They show that unfavorable cardiovascular profiles are more often 11–14 Operationalization of study variables in both samples (KiGGS and found in obese children/adolescents of certain ethnic groups. APV) We therefore defined the following hypothesis: (1) Overweight/ Weight status for age and gender was assessed by BMI (body weight (kg)/ obese children/adolescents with a Turkish migration background 2 body height (m) ). BMI was standardized by conversion to an SDSLMS score show a higher prevalence of hypertension and dyslipidemia than using the German national reference data that are also valid for Austrian their counterparts of German/Austrian/Swiss origin. (2) No ethnic and Swiss children.25 According to German guidelines, normal weight in differences in the prevalence of hypertension and dyslipidemia children was defined as a BMI o90th percentile, overweight as a BMI are seen in normal-weight children/adolescents. 490th and ⩽ 97th percentile, obesity as a BMI 497th and ⩽ 99.5th percentile and extreme obesity as a BMI 499.5th percentile.19 BP was classified for age, sex and height based on the Fourth Report on PATIENTS AND METHODS the Diagnosis, Evaluation and Treatment of High BP in Children and 26 Subjects Adolescents, according to the guidelines of the European Society of Hypertension.27 Hypertension was diagnosed if either systolic and/or Data from two major surveys were analyzed: first, the ongoing multicenter diastolic BP was elevated above the 95th percentile for age and gender, APV (Prospective Documentation of Overweight Children and Adolescents) according to the US population-based reference values (Fourth Report).26 initiative records routine data on overweight/obese children/adolescents We used the Fourth Report to present internationally comparative data. presenting at specialized treatment institutions in Germany, Switzerland Abnormal lipid levels (dyslipidemia) were defined according to the and Austria. For the collection of anonymized data at the participating APV guidelines of the American Heart Association for primary prevention of centers, a computer software is applied for standardized longitudinal atherosclerotic CVD beginning in childhood:28 total cholesterol above documentation of demographics, weight category and medical comorbid- − 1 − 1 15 5.18 mmol l (4 200 mg dl ),