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Parental Overweight and Hypertension Are Associated with Their Children's Xu et al. Nutrition & Metabolism (2019) 16:35 https://doi.org/10.1186/s12986-019-0357-4 RESEARCH Open Access Parental overweight and hypertension are associated with their children’s blood pressure Renying Xu1, Xiaomin Zhang1, Yiquan Zhou1, Yanping Wan1* and Xiang Gao2* Abstract Background: We evaluated the association between parental factors (overweight, history of hypertension, and education level) and children’s blood pressure status. Further, we evaluated to what extent the potential association could be interpreted by children’s adiposity indices. Methods: The current study included 3316 Chinese school students (1579 girls and 1737 boys, aged 6–14 years) and their parents. Parents reported information on their height, body weight, history of hypertension, and the highest education level. Trained medical staff measured children’s blood pressure, height, body weight, waist circumference (WC), and percentage of body fat (PBF, assessed by bio-impedance method). Z-score of all three indices were calculated and used in the analysis. We used generalized linear model to evaluate the association between parental information and z-score of children’s blood pressure. Meditation analysis was used to evaluate the proportion contributed by z-score of children’s adiposity indices (BMI, WC, and PBF). Results: We found that parental overweight and hypertension, but not parental education level, were significantly associated with children’s systolic and diastolic blood pressure (P < 0.05 for all). Approximately 30.4–92.2% of the association between these two parental factors and children’s systolic blood pressure were mediated by children’s adiposity indices, and 22.3–55.6% for children’s diastolic blood pressure. The strongest meditative factor, among the three obesity indices, was children’s BMI z-score. Conclusions: The association between parental factors and children’s blood pressure was mainly mediated by children’s adiposity indices. Keywords: Parents, Children, Body mass index (BMI), Waist circumference (WC), Percentage of body fat (PBF), Blood pressure Background stroke and acute myocardial infarction [3, 4]. Identifying The prevalence of hypertension among Chinese children risk factors for childhood hypertension is of significance and adolescents increased from 6.9 to 10.7% in the past to ameliorate medical burden, which is associated with two decades based on a National survey [1]. Without adulthood cardiovascular diseases. proper intervention, childhood hypertension will track Several parental factors, such as obesity [5–7], history into adult and dramatically exaggerate adult hyperten- of hypertension [8–10], education level [11–13], and sion [2] and related cardiovascular diseases such as family income [11, 12, 14, 15], were shown to be associ- ated with childhood hypertension. It is meaningful to block the transmission from parents to children if we * Correspondence: [email protected]; [email protected] The study was supported by the grants from Pu Dong Medical Bureau could find the underlying mediators. Previous studies re- (PW2016D-05), and by the grant from Shanghai Key Laboratory of Pediatric ported that these associations might be mediated by Gastroenterology and Nutrition (No.17DZ2272000) ’ 1 children s body mass index (BMI), a key driving factor Department of Clinical Nutrition, Ren Ji Hospital, School of Medicine, – Shanghai Jiao Tong University, Shanghai, China for childhood hypertension [12, 14 16]. However, evi- 2Department of Nutritional Science, The Pennsylvania State University, dence remains inconsistent: positive [5, 6] and null [7] University Park, PA 16802, USA © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Xu et al. Nutrition & Metabolism (2019) 16:35 Page 2 of 8 association between parental BMI and children’s blood Outcome pressure were reported in previous studies. Further, Children’s resting blood pressure (BP) was measured by whether waist circumference (WC) and percentage of 6 doctors and 4 nurses twice on the children’s right arm body fat (PBF) in parents, which are believed to be bet- in a quiet room after resting for at least 10 min, using a ter indices in reflecting body fat than BMI, are associ- mercury sphygmomanometer and a special cuff that fit ated with offspring blood pressure status remains 2/3 of the children’s arm. Systolic blood pressure (SBP) unclear. Therefore, we performed a cross-sectional study is the point at which the onset of Korotkoff sounds and in 3316 Chinese parents-children trios to evaluate the the fourth Korotkoff sound (K4) was used to define dia- association between parental factors (overweight, history stolic blood pressure (DBP) [19]. The interval between of hypertension, and education level) and childhood the two blood pressure measurements was at least 10 blood pressure status. We further evaluated meditative min and the average value of BP was recorded to the effect of children’s adiposity indices, including BMI, nearest 1 mmHg. Because children’s body size changes waist circumference (WC), and percentage of body fat rapidly during development and blood pressure keeps (PBF)] on these potential associations. changing as well, z-score of blood pressure was calcu- lated based on a national survey [20]. Methods Potential mediators Study population We examined whether children’s obesity indices (BMI, The current study was conducted in five primary schools WC, and PBF) were mediators for the association be- in Gao Hang Town, Shanghai, China, as detailed previ- tween parental information (e.g., obesity status) and ously [17]. Parental information including height, body childhood blood pressure. Children’s height (to the near- weight, history of hypertension, and the highest educa- est 0.1 cm), weight (to the nearest 0.1 kg), and body fat tion level was self-reported via a questionnaire. Trained (BIA method; TBF-410, Tokyo, Japan) were measured medical staff measured children’s blood pressure in Sep- while children were barefoot and in underwear. Body fat tember 2014. We have 28 investigators to perform the was recorded as PBF (fat mass/body weight*100) to the survey. Among them, 6 doctors and 4 nurses assessed nearest 0.1%. BMI was calculated as the body weight children’s blood pressure, 10 registered dietitians con- (kg) divided by the height squared (m2). BMI z-score ducted face-to-face interview, and the remain trained was calculated according to the Shanghai age and sex medical staffs collected anthropometrical data (e.g., body specific height and body weight 2007 standards [21]. weight and waist circumference). Approximately 300 WC was measured at the midpoint between the iliac children were surveyed during each visit. The number of crest and the lower rib (to the nearest 0.1 cm). Z-score eligible participants was 3781, after excluding those who of PBF and WC was also calculated [22, 23]. declined to participate the study (n = 58), those born preterm (n = 77), those with missing data (n = 325), this Assessment of other potential confounders resulted in 3321 participants. We further excluded five We collected children’s information on age, sex, birth participants old than 14 years, included were 3316 weight, infant feeding pattern (breastfeeding, part breast- parents-children trios (1579 girls and 1737 boys, aged feeding, or bottle-feeding), physical activities (< 1 or ≥ 1h 6–14 years) in the analysis. The details of participant re- per day), and night sleep duration (< 9 or ≥ 9 h per day), cruitment were shown in Additional file 1: Figure S1. consumption of carbonated beverage (≤3 or ≥ 4 bottles Parents signed informed consent forms. The study was per week), western fast food (≤4 or ≥ 5 times per month), approved by the Ethics Committee of Ren Ji Hospital, traditional Chinese fried food (≤4 or ≥ 5 times per week), School of Medicine, Shanghai Jiao Tong University. and processed meat (≤4 or ≥ 5 times per week), by the aforementioned questionnaire, which was completed by Exposures the parents. Parents reported their information on height, body weight, history of hypertension, and the highest educa- Statistical analyses tion level via a questionnaire. Parental BMI was calcu- We performed all statistical analyses by SAS version 9.4 lated and categorized as following: ‘normal’ (BMI < 24.0 (SAS Institute, Inc., Cary, NC). Formal hypothesis test- kg/m2), or ‘overweight’ (BMI ≥24.0 kg/m2) according to ing was two-sided with a significant level of 0.05. the Working Group of Obesity in China (WGOC) cri- Potential mediator were examined using the method teria for adults [18]. Parental education level was cat- described by Baron and Kenny’s[24]. We used PROC egorized as ‘low’ (≤middle school) or ‘high’ (≥high CORR to evaluate the association between parental BMI school) while history of hypertension was categorized and z-score of children’s adiposity indices and z-score of as ‘yes’ or ‘no’. blood pressure adjusting for children’s age, sex, birth Xu et al. Nutrition & Metabolism (2019) 16:35 Page 3 of 8 weight, infant feeding, diet, physical activities, and night and 46.3% for z-score of children’s BMI, WC, and PBF, sleep. PROC GLM was used to evaluate the association respectively, and it ranged from 30.7 to 52.4% for the as- between parental BMI and other factors (history of sociation between paternal overweight and children’s hypertension and education level) and children’s blood DBP z-score (Table 4). The proportion ranged from 50.7 pressure. We included a number of potential con- to 92.2% for maternal overweight and SBP z-score while founders in the model: age (y), sex, height (cm), birth it was between 29.6 to 55.6% for maternal overweight weight (g), infant feeding (breastfeeding, part breastfeed- and DBP z-score (Table 5).
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