Family Practice 2013; 30:629633 The Author 2013. Published by Oxford University Press. All rights reserved.

doi:10.1093/fampra/cmt048 For permissions, please e-mail: journals.permissions@oup.com.

Advance Access publication 25 September 2013

Obesity and asymptomatic hypertension among children

aged 613years living in Bursa,Turkey
HakanDemircia,*, CagatayNuhoglub, Ismail SerkanUrsavasc,
SerhatIsildakc, Ebru OnukerBasaranc and Mehmet YasarKlcc
a
Department of Family Medicine, Sevket Yilmaz Training and Research Hospital, Bursa, bDepartment of Pediatrics, Haydarpasa
Numune Training and Research Hospital, Istanbul and cDepartment of Family Medicine, Fethiye Bulvar Family Practice Unit,
Bursa, Turkey.
*Correspondence to Hakan Demirci, Department of Family Medicine, Sevket Yilmaz Training and Research Hospital, Yildirim,
Bursa 16310, Turkey; E-mail: drhakandemirci@hotmail.com
Received 5 April 2013; Revised 24 July 2013; Accepted 30 July 2013.

Introduction. Hypertension is an independent risk factor for cardiovascular disease. It is known

that essential hypertension begins at a very early age. Recently, there have been reports of an
increase in childhood hypertension, which has been attributed to an increase in the prevalence
of childhood obesity. Obesity-dependent or independent asymptomatic hypertension can only be
determined by random blood pressure measurements in children.
Objective. In this study, we aimed to investigate the prevalence of obesity and asymptomatic
hypertension among children living in Bursa, Turkey.
Methods. One thousand children living in Nilfer district and being served by the Fethiye Bulvar
Family Health Care Center were enrolled in this study. All seven family physicians working at the
centre participated in the study.
Results. Eighty-five children (8.5%) were determined to be hypertensive. One hundred and twelve
children (11.2%) were obese. Blood pressure and body mass index (BMI) increased with age, with
peak prevalence of hypertension at age 12 and of obesity at age 10.
Conclusions. The prevalence of obesity and hypertension is high among school-age children in
Turkey. Family physicians should consistently perform blood pressure and BMI measurements as
a part of well child visits through late childhood.
Keywords. Childhood obesity, hypertension (high blood pressure), medical comorbidity, paedi-
atrics, primary care, public health.

Introduction 95th percentile, adjusted for age and gender.8 Obesity

Many studies have evaluated the prevalence of obesity
and hypertension.14 In the past decade, an increase in
childhood hypertension has been noted. This surprising
increase has been attributed to a simultaneous increase
in obesity, increased salt and calorie consumption, lack
of physical activity and other factors, such as stress.5
Hypertension and related health problems lead
to important mortality and morbidity over time.
Hypertension in children is less common than in adults;
however, it has been suggested that the latter is an
extension of the former.6,7 If this is the case, then diag-
nosing and treating hypertension at an earlier stage
should be a priority.
Obesity is another important public health problem
and is associated with hypertension, cardiovascular dis-
ease, diabetes mellitus and atherosclerosis. Childhood
obesity is defined as a body mass index (BMI) over the
in childhood is most common in developed countries.
For example, 11% of children in the USA are obese.
However, recent studies have shown that the preva-
lence of obesity is increasing all over the world.9
The prevalence of obesity and hypertension is
increasing, and these diseases have a great impact on
health. To overcome these diseases, we must know their
current prevalence. In this study, we aimed to determine
the prevalence of obesity and hypertension in school-
age children as an aid in planning a defence strategy.
Methods
According to Turkish Health Ministry data, 396 530
children, aged 613years, were living in Bursa in 2011.
Using this information and recent data on the preva-
lence of hypertension and obesity in Bursa and Turkey,

629
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 630 Family PracticeThe International Journal for Research in Primary Care

Table1 Gender and age distribution in the study group

Age (years)

6 7 8 9 10 11 12 13 Total

Female Count 62 88 71 56 62 52 54 25 470

% Within gender 13.2 18.7 15.1 11.9 13.2 11.1 11.5 5.3 100.0
% Within age (year) 52.1 48.4 51.8 42.4 48.1 44.1 48.6 34.7 47.0
Male Count 57 94 66 76 67 66 57 47 530
% Within gender 10.8 17.7 12.5 14.3 12.6 12.5 10.8 8.9 100.0
% Within age (year) 47.9 51.6 48.2 57.6 51.9 55.9 51.4 65.3 53.0
Total Count 119 182 137 132 129 118 111 72 1000
% Within gender 11.9 18.2 13.7 13.2 12.9 11.8 11.1 7.2 100.0

we calculated a minimum sample size of 306 cases for and the KruskalWallis test for multiple independent
our study (=0.05). Because of our study aims (sub- groups, Students t-test for two groups, multiple lin-
group size and statistical test selection), we raised our ear regression forward method and linear correlation
sample size to 1000 children, maintaining a similar coefficient. P values <0.05 were considered statistically
gender and age distribution to the population in Bursa significant.
while staying within the limits of our study budget.
We conducted this cross-sectional study in Nilfer-9
Fethiye Bulvar Family Practice Offices in Bursa, Turkey. Results
Bursa City is composed of three central urban regions,
including Nilfer district, which is located on the west The mean age of the children was 9.12.2 years, and
side of the city. We registered 978 girls and 1120 boys the female/male ratio was 0.89. Gender distribution dif-
aged 613years. The study lasted for 12months, from 1 ferences by age group (Table 1) were not statistically
February 2011 through 31 January 2012. All seven fam- significant (2=8.710, d.f.=7, P=0.274).
ily practitioners working in the centre participated in The mean systolic blood pressure of the girls was
thestudy. 10112 mmHg and of the boys was 10212 mmHg.
A letter with the study description and an invitation This difference was statistically significant (t=2.088,
to participate was sent to all parents in the study area. d.f.=998, P<0.05). Mean diastolic blood pressure was
The parents of 470 (47%) girls and 530 (53%) boys and 659mmHg for both girls and boys (P > 0.05). Mean
the children themselves agreed to participate in the blood pressure results by age and gender are shown in
study. Table3.
Physicians measured systolic and diastolic blood For girls, differences among age groups in mean sys-
pressure (mmHg) with manually operated sphygmoma- tolic blood pressure (F=15.094, d.f.=7, P<0.001) and
nometers appropriate for the wrist size of each enrolled in diastolic blood pressure (F=7.601, d.f.=7, P<0.001)
child. The mean of three consecutive measurements were statistically significant (one-way ANOVA).
the 95th percentile in one visit with adequate inter- Systolic (r=0.401, P<0.001) and diastolic (r=0.313,
vals constituted a diagnosis of hypertension. Values
between the 90th and 95th percentiles were categorized Table2 Multiple linear regression analysis of blood pressure results
as pre-hypertension.
A nurse measured each childs weight (kg) and height Dependent R2 t P
(m) in light clothing with no shoes. Ashort history was variable
taken for each child, including chronic illnesses and cur-
rent medications. Systolic Female BMI 0.18 0.313 7.025 <0.001
BMI was calculated as weight/height2 (kg/m2). BMI blood Age 0.267 5.978 <0.001
pressure BMI and age 0.24
scores were evaluated using percentile charts prepared
Male BMI 0.22 0.387 9.237 <0.001
for Turkish children.8 Age 0.187 4.459 <0.001
The Ethics Committee of Istanbul Haydarpaa BMI and age 0.25
Numune Training and Research Hospital approved the Diastolic Female BMI 0.17 0.307 6.614 <0.001
study. Trial registration was not required for the study. blood Age 0.181 3.899 <0.001
Statistical analysis was performed using SPSS pocket pressure BMI and age 0.15
version 20. We used descriptive statistics (percent- Male BMI 0.13 0.281 6.263 <0.001
Age 0.139 3.085 <0.01
age, arithmetic mean and SD), the chi-square test for
BMI and age 0.11
stratified data, one-way analysis of variance (ANOVA)

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 Obesity and hypertension among Turkish children
P<0.001) blood pressure measurements for girls cor-
related withage.
For boys, differences among age groups in mean
systolic blood pressure (KruskalWallis, P < 0.001)
and mean diastolic blood pressure (one-way ANOVA;
F=6.261, d.f.=7, P<0.001) were statistically significant.
Systolic (rs=0.349, P<0.001) and diastolic (r=0.260,
P<0.001) blood pressure measurements for boys cor-
related withage.
Eighty-five children (8.5%) had hypertension and 23
(2.3%) had pre-hypertension. Hypertension and pre-
hypertension distributions by age group are shown in
Table5 and Figure1. Peak obesity prevalence was seen
at 10 years of age; peak hypertension prevalence was
seen at age12.
Thirty-three children (3.3%) had systolic hyper-
tension and 18 (1.8%) had diastolic hypertension.
Thirty-four children (3.4%) had combined systolic and
diastolic hypertension.
Mean BMI values (173 for girls, 184 for boys)
were not significantly different between gender groups
(MannWhitney U-test, P > 0.05). BMI for each age
group is shown in Table4.
Mean BMI values were significantly different among
age groups for both girls and boys (KruskalWallis,
631
P<0.001). BMI correlated with age in girls (rs=0.437,
P<0.001) and in boys (rs=0.452, P<0.001).
We evaluated blood pressure (dependent variable),
BMI and age using forward selection multiple linear
regression analysis (Table2).
While BMI and age together explained 24% of sys-
tolic blood pressure changes in girls, this proportion
was 18% for BMI alone. These proportions were 25%
and 22% forboys.
While BMI and age explained 17% of diastolic blood
pressure changes for girls, this proportion was 15% for BMI
alone. These proportions were 13% and 11% forboys.
BMI and age significantly correlated with blood pres-
sure levels in children 613years of age. There were 112
children (11.2%) with obesity in the study group. Thirty-
four children (3.4%) had both obesity and hypertension.
Discussion
Previous studies have found hypertension prevalence
ranging from 6.3% to 12.3% among school-age children
living in Turkey.10,11 We determined that the frequency
of asymptomatic hypertension in the Nilfer region was
8.5%. We also found that mean hypertension values

Table3 Mean blood pressure changes by age and gender

Blood pressure Age (years)

(mmHg)
6 7 8 9 10 11 12 13 Total

Systolic Female 9510 9511 9911 10210 10112 10211 11012 1109 10112
Male 9810 9811 9811 10010 10313 10712 10613 11213 10212
Total 9710 9611 9911 10110 10213 10513 10813 11112 10112
Diastolic Female 617 619 649 659 6510 6610 699 717 659
Male 628 638 639 648 6610 668 669 709 659
Total 617 628 639 658 6610 669 679 719 659

Figure1 Hypertension, pre-hypertension and obesity percentage related to age

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 632 Family PracticeThe International Journal for Research in Primary Care

Table4 Changes in mean BMI by age

BMI Age (years)

6 7 8 9 10 11 12 13 Total

Female 15.52.3 16.12.5 15.92.1 17.23.4 18.23.2 18.43.7 19.84.1 19.73.3 17.33.4
Male 15.82.4 16.02.3 16.52.7 17.33.1 18.33.6 19.34.1 19.43.5 20.23.8 17.73.5
Total 15.72.4 16.12.4 16.22.5 17.33.2 18.23.4 18.93.9 19.63.8 20.03.6 17.53.5

Table5 Distribution of obesity and hypertension by age

Age (years)

6 7 8 9 10 11 12 13 Total

Hypertension 8 (6.7%) 11 (6.0%) 9 (6.6%) 9 (6.8%) 13 (10.1%) 11 (9.3%) 16 (14.4%) 8 (11.1%) 85 (8.5%)
Pre-hypertension 0 0 1 (0.7%) 2 (1.5%) 5 (3.9%) 6 (5.1%) 4 (3.6%) 5 (6.9%) 23 (2.3%)
Obesity 16 (13.4%) 19 (10.4%) 12 (8.8%) 17 (12.9%) 21 (16.3%) 12 (10.2%) 10 (9.0%) 5 (6.9%) 112 (11.2%)

increased year by year, with a peak at puberty, probably
due to hormonal changes.
Kayran et al.12 found that the prevalence of child-
hood obesity was 5.3%. Another study reported an obe-
sity prevalence of 7.1% among school-age children.13
In the present study, we found that 11.2% of children
aged 613 years were obese. Lurbe et al.14 found an
association between systolic hypertension and BMI in
children. In the present study, we also found that BMI
correlated with blood pressure in children.
Our study had several limitations. We did not
attempt to reach non-responder families once
we achieved the target number of participants.
However, our results can be generalized to the
Bursa population because gender and age distri-
bution of the study group were similar to those
found in Bursa. Further research will be needed to
confirm whether or not these findings can in turn
be generalized to the entire population of Turkey.
Invitation to a study with a letter indicating a
specific illness might result in a higher response
rate from individuals suffering from the indicated
health problem. This may cause overestimation of
prevalence in epidemiologic studies. However, this
is not true for childhood hypertension, which is
usually asymptomatic. Finally, it would be better if
we had taken the pubertal history of participants
to determine the effect of puberty on obesity and
hypertension, both of which had peak prevalence
at around the time of puberty.
Conclusions
Our results show that the prevalence of childhood obe-
sity in this urban Turkey population is similar to rates
seen in the developed countries such as USA. The peak
prevalence of hypertension follows that of obesity in
the late childhood period. Importance of the well child
visits including BMI and blood pressure measurements
through puberty can be emphasized to family physi-
cians for early detection and better management of these
conditions.
Acknowledgements
The authors express their thanks to Dr Bahri Oztrk
for his cooperation.
Declaration
Funding: none.
Ethical approval: The Ethics Committee of Istanbul
Haydarpaa Numune Training and Research Hospital
approved the study.
Conflict of interest: none.
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