Journal of Human Hypertension

https://doi.org/10.1038/s41371-018-0030-9

ARTICLE

Sugar-sweetened beverages and school students’ hypertension in

urban areas of Nanjing, China
Zhenzhen Qin1 Fei Xu1,2 Qing Ye1 Hairong Zhou1 Chao Li1 Jing He2 Zhiyong Wang1 Xin Hong1
● ● ● ● ● ● ● ●

Xiangyu Hou3

Received: 21 June 2017 / Revised: 15 October 2017 / Accepted: 6 November 2017

© Macmillan Publishers Ltd., part of Springer Nature 2018

Abstract
Literature showed that sugar-sweetened beverages (SSBs) could increase the risk of developing hypertension in school
students, but there is no reported evidence from China yet, so this study aims to investigate the association of the SSBs
consumption and school students’ hypertension in urban areas of Nanjing, China. A cross-sectional survey was conducted
among primary and junior high school students selected from 32 primary schools and 16 junior high schools using a multi-
stage random sampling method, with a total number of 10,091 participants involved. The mean age of Grade 4 is 9.04 ±
1234567890();,:

0.38, while the mean age of Grade 7 is 12.03 ± 0.41. Blood pressure was measured and SSBs consumption was reported
using a validated questionnaire. The overall prevalence of hypertension was 4.5% among the participants. After adjustment
for school, parental education, physical activity, diet intake including meat and snacks, participants who had an experience
of SSBs intake were at a higher risk of developing hypertension (odds ratio (OR) = 1.40, 95% confidence interval (CI) =
1.15, 1.70) compared with those who had no experience of SSBs intake. A significant association between the consumption
of SSBs and hypertension was observed among the students who were at a healthy weight (OR = 1.78, 95% CI = 1.20,
2.65), as well as who were overweight or obese (OR = 1.28, 95% CI = 1.01, 1.61). SSBs may play a contributing role in
developing childhood hypertension in this population in China, which is of important implications for future population-
based childhood hypertension intervention in China and other countries.

Introduction increasing prevalence of hypertension worldwide [3]. In

In recent years, several studies have shown strong evidence
that increased blood pressure (BP) levels during childhood
could effectively predict hypertension and subsequent car-
diovascular diseases in adulthood [1, 2]. This has been a
significant topic over the past decade due to the ever
Zhenzhen Qin and Fei Xu contributed equally to this work.
* Fei Xu
frankxufei@163.com
1 the relationship between SSBs and school students’
Department of Non-communicable Disease Prevention, Nanjing
Municipal Center for Disease Control and Prevention, 2, Zizhulin,
Nanjing, China
2
Department of Epidemiology and Biostatistics, School of Public
Health, Nanjing Medical University, Nanjing, China
3
School of Public Health and Social Work, Faculty of Health, The
Queensland University of Technology, Brisbane, QLD, Australia
addition to the reported underlying preventable risk factors,
such as tobacco usage, obesity, chronic kidney disease, high
salt intake, high fat diet, type A behavior pattern, and excess
alcohol intake [4, 5], recently sugar-sweetened beverages
(SSBs) were reported to be associated with hypertension
development among school students.
SSBs provide striking amount of calories for school
students, contributing 10–15% of total daily energy [6].
Several studies revealed significantly positive associations
between consumption of SSBs and the risk of
developing hypertension [7], while one study from Mexico
showed no link between SSBs and school students’
hypertension [8]. To date, there is no study reporting
hypertension in Mainland China, despite the rapid economic
growth and wide consumption of SSBs in China [9],
particularly in urban areas. The purpose of our study is to
explore the relationship between the consumption of
SSBs and higher BP in school students in urban areas
of Nanjing, China.

Methods
Study design and recruitment of participants
This study was conducted in September 2013 in urban areas
of Nanjing City, China. Nanjing is located in Eastern China,
with a total population of more than 8 million in 2013.
Participants were students in Grades 4 and 7 selected from
primary and junior high schools within the eight urban
districts of Nanjing using a multi-stage random sampling
approach. Four primary and two junior high schools were
chosen from each of the eight urban districts (32 primary
and 16 junior high schools in total). All 4th and 7th graders
from the selected schools were invited to take part in the
study, excluding those who had a history of secondary
hypertension, or were recognized with the early phase of
primary hypertension or have already been treated/or not yet
treated hypertension, by asking their head teachers and
school doctors, resulting in 10,447 eligible participants.
This project was approved by the Academic and Ethical
Committee of Nanjing Municipal Center for Disease Con-
trol and Prevention (Nanjing CDC). Signed informed con-
sents for this study were obtained from parents/guardians
and schools prior to the survey. All personally identifiable
information was removed prior to data analysis.
Questionnaire and measurement
All participants were invited to complete a standard self-
administered questionnaire which includes students’ age,
gender, school, grade, class, recreational physical activity (PA)
time, TV viewing time, sleep time, weekly diet, and their
parents’ educational status. The weekly diet, including SSBs
intake, as well as intakes of meat and snacks, were assessed
using a validated Food Frequency Questionnaire [10].
The body weight (to the nearest 0.1 kg) and height (to the
nearest 0.01 m) were measured by trained research staffs. The
BP was measured two times by registered physicians using
mercury sphygmomanometers while following the recom-
mended procedure by the US National Heart, Lung, and Blood
Institute. The mean values of systolic BP (SBP) and diastolic
BP (DBP) were then calculated. Hypertension was defined as
SBP and/or DBP that is ≥95th percentile according to the
gender-specific and age-specific profile for Chinese children
and adolescents in Mainland China [11]. Participants were
classified into hypertension or non-hypertension in this study.
Regarding the consumption of SSBs, the question “How
many times did you drink sugar-sweetened beverages, like
Sprite and Coca-Cola, in the past week (please respond zero
if you did not drink)?” was used to collect data on con-
sumption of SSBs and its frequency. The similar question
was used to gather information on consumption frequency
of meat and snacks, separately.
Z. Qin et al.
Body mass index was calculated as weight in kilograms
divided by the square of the height in meters, and body
weight status were calculated according to the specifically
recommended reference for Chinese school students [12].
Sufficient PA was defined as at least 60 min of moderate-
intensity PA or vigorous-intensity PA per day, otherwise
insufficient PA [13]. Parental educational levels were
categorized as junior high school or below, senior high
school, and bachelor degree or above.
Date management and statistical analysis
The χ2 test was used to calculate the difference of distributions
for SSBs consumption and hypertension among the partici-
pants, respectively. Logistic regression models were used to
calculate the odds ratios (ORs) and their 95% confidence
intervals (CIs) of achieving an outcome event (hypertension) in
each of the two comparison groups (SSBs consumers and non-
SSBs consumers), with adjustment for school, parental edu-
cational levels, PA time, and diet intake of meat and snacks.
Data were double-entered (entered once and checked
once) and cleaned with EpiData 3.1 (The EpiData
Association 2008, Odense, Denmark) and managed and
analyzed using SPSS 20.0 (SPSS Inc., Chicago, IL, USA).
Results
Of the 10,447 eligible participants, 10,091 (response rate =
96.6%) completed the survey. Table 1 presented the socio-
demographic characteristics of the participants. There were
5,246 (52.0%) and 4,845 (48.0%) from Grade 4 and Grade 7,
respectively, with 5,355 (53.1%) boys and 4,736 (46.9%)
girls. The mean age of Grade 4 is 9.04 ± 0.38, while the mean
age of Grade 7 is 12.03 ± 0.41. Almost two-thirds of parents
had at least senior high school educational attainment.
Table 1 Selected demographic characteristics of participants in urban
areas of Nanjing, China (N, %)
Participants Overall Grade
4 7
N 10,091 5,246 4,845
Boys 2,822 (53.8) 2,533 (52.3)
Age (years) 9.04 ± 0.38 12.03 ± 0.41
Family population
≤3 2,503 (47.7) 2,931 (60.5)
>3 2,743 (52.3) 1,913 (39.5)
Parental educational
Junior high school or below 1,860 (35.5) 1,338 (27.6)
Senior high school 1,249 (23.8) 1,444 (29.8)
Bachelor degree or above 2,137 (40.7) 2,063 (42.6)
Sugar-sweetened beverages and school students’....

Table 2 Distribution of SSBs consumption and hypertension among urban participants in Nanjing, China
Exposure variables Number of participants (N, %) P value Number of participants (N, %) P value
a
Non-SSBs SSBs Non-hypertension Hypertension
consumers consumers

Gender
Boy 2,520 (47.1) 2,835 (52.9) <0.001 5,056 (94.4) 299 (5.6) <0.001
Girl 2,673 (56.4) 2,063 (43.6) 4,583 (96.8) 153 (3.2)
Grade
4 3,046 (58.1) 2,200 (41.9) <0.001 5,171 (98.6) 75 (1.4) <0.001
7 2,147 (44.3) 2,698 (55.7) 4,468 (92.2) 377 (7.8)
Parental education
Junior high school or below 1,562 (48.8) 1,636 (51.2) <0.001 3,068 (95.9) 130 (4.1) 0.06
Senior high school 1,244 (46.2) 1,449 (53.8) 2,551 (94.7) 142 (5.3)
Bachelor degree or above 2,387 (56.8) 1,813 (43.2) 4,020 (95.7) 180 (4.3)
DBP diastolic blood pressure, SBP systolic blood pressure, SSB sugar-sweetened beverage
a
Hypertension was defined as SBP and/or DBP that is ≥95th percentile according to the gender-specific and age-specific profile for Chinese
children and adolescents in Mainland China

Distributions of SSBs consumption and hypertension among Table 3 The associations between SSBs consumption and the risk of
urban participants were shown in Table 2. Overall, 48.5% of all incident hypertension among urban students in Nanjing, China
students had an experience of consuming SSBs. Boys (52.9%)
Variable SSBs Participants with OR (95% CI)b
had a higher proportion of SSBs intake than girls (43.6%), consumptiona hypertension (n/N, %)
while students of Grade 7 (55.7%) had a higher proportion of
SSBs intake than students of Grade 4 (41.9%). With the Overall
development of parental education levels, the proportion of No 203/5,193, 3.9 1
SSBs intake decreased among the participants (P < 0.001). The Yes 249/ 4,898, 5.1 1.40
(1.15,1.70)
total prevalence of hypertension was 4.5%. Compared with
girls, boys had a higher risk of developing hypertension (P < Body weight statusc
0.001). The prevalence rate in students of Grade 7 is sig- Normal
nificantly higher than students of Grade 4 (P < 0.001). There No 43/3,377, 1.3 1
was no significant difference in the rate of hypertension among Yes 67/3,221, 2.1 1.78
(1.20,2.65)
students with different parental educational levels.
Overweight/obesity
Table 3 displays the relationship between SSBs con-
sumption and the risk of developing hypertension among No 160/1,816, 8.8 1
students. After adjusted for school, parental educational Yes 182/1,677, 10.9 1.28
(1.01,1.61)
levels, PA time, and diet intake of meat and snacks, a sig-
nificant relationship between SSBs consumption and CI confidence interval, OR odds ratio, SSB sugar-sweetened beverage
hypertension was observed (OR = 1.40, 95% CI = 1.15, a
Consumption frequency of SSBs, referred to having an experience of
1.70). Considering that body weight was correlated with consuming SSBs, was classified into two sub-groups of students: non-
SSBs consumers = no and SSBs consumers = yes
hypertension, we further evaluated the association between b
Adjusted for school, parental educational attainment, PA time, diet
the consumption of SSBs and hypertension in students by intake of meat and snacks
body weight status. Significant associations between the c
Body weight status stratification by Group of physical fitness and
consumption of SSBs and hypertension were observed health research of Chinese school students. Reports on the physical
among the students who were at a healthy weight (OR = fitness and health research of Chinese school students in 2010
1.78, 95% CI = 1.20, 2.65), as well as who were overweight
or obese (OR = 1.28, 95% CI = 1.01, 1.61).
areas of Nanjing, China. It was observed that there were
48.5% of participants having SSBs consumption in a week
Discussion and the prevalence of hypertension was 4.5% within school
students. Moreover, there was a positive association
This study examined the association between SSBs con- between SSBs consumption and the risk of experiencing
sumption and hypertension among school students in urban hypertension among those school students.

It has been documented that SSBs consumption for school
students was usually influenced by a lot of factors, including
demographic, socioeconomic, dietary, psychosocial, and
environmental characteristics [14, 15]. Boys than girls had
higher level of interest in drinking SSBs (52.9 vs. 43.6%) in
this study, which might, in part, explain that the proportion of
SSBs intake was higher among boys than within girls.
Moreover, girls are more concerned with their body shape and
tend to eat healthier (i.e., more fruit, vegetables, and less
SSBs) relative to boys [16]. Economic factors appeared to be
of importance for students’ soft drink consumption [17], stu-
dents in junior high school tended to intake more SSBs than
the pupils (55.7 vs. 41.9%) could be attributed to their parents’
financial support in the form of more pocket money.
The prevalence of hypertension was examined to be
higher among boys than girls in this study, which was in
line with previous report from Xu et al. [18] among multi-
ethnic Chinese adolescents aged 8–18 years old. The dif-
ference in hormone and lifestyles between boys and girls
might partly contribute to this gender disparity in hyper-
tension among students [19]. Consistent with other studies
[20, 21], the risk of experiencing hypertension was
observed with increasing age among participants in our
study. It has been documented that high school students had
heavier academic and psychological distress, leading to
fatigue, inhibition, and imbalances of the brain cortex, and
consequently causing elevated BP [22, 23].
There were several mechanisms behind the association of
SSBs consumption with hypertension. SSBs contain large
amounts of readily absorbable sugars like a mixture of fruc-
tose and glucose. Fructose was the most potent antinatriuresis
agent which could acutely influence salt metabolism and
significantly elevated systolic BP [24]. Unlike other sugars,
fructose could cause serum uric acid levels to rise rapidly
[25]. It was reported that increased uric acid levels were
independent markers of cardiovascular disease risk in adults.
Moreover, serum uric acid levels were strongly associated
with cardiovascular risk factors like hypertension and the
metabolic syndrome in children and adolescents [26].
Therefore, it is reasonable to suppose that serum uric acid
may contribute to the pathogenesis of hypertension. In addi-
tion, salt intake was well known to play a crucial role in the
genesis of hypertension [27]. A modest positive relationship
has been examined between SSBs consumption and dietary
salt intake, which may, in apart, account for the association of
SSBs intake with hypertension [28, 29].
Considering that SSBs consumption was positively
associated with overweight [30] and body weight was one
of the main risk factors of hypertension [31], we further
examined the relationship between SSBs consumption and
hypertension by groups of body weight. Based on such
stratified analysis, SSBs consumption was in positive rela-
tion to the risk of experiencing hypertension among
Z. Qin et al.
participants within each stratum of body weight, which
suggesting that the association of SSBs intake with hyper-
tension was independent of body weight in this study.
To the best of our knowledge, this is the first study
investigating the relationship between SSB consumption and
hypertension among school students in China. The strength of
our study included (1) large number of participants with
sample size estimation; (2) appropriate analysis methods were
used to examine SSB–hypertension association with potential
confounders considered; (3) the SSB–hypertension associa-
tion was also investigated among participants by body weight
status, attempting to eliminate mediation of body weight; (4)
strict quality control approaches were implemented in field
survey, yielding a very high response rate (96.6%).
However, limitations also needed to be mentioned in our
study. First, data from cross-sectional survey could not yield
causal relationship between SSBs and hypertension. Sec-
ond, a questionnaire was used to gather information on
foods consumption, which might cause recall bias, although
this questionnaire was validated for Chinese children. Third,
family history of hypertension and salt intake were not
considered in our analysis due to data limitation.
In summary, SSBs were observed to be positively asso-
ciated with hypertension among Chinese school students in
urban areas of regional China. In future, prospective studies
are needed to further explore the influence of SSBs
consumption on the development of hypertension among
children.
Summary Table
What is known about topic
● Recently, SSBs were reported to be associated with
hypertension among school students.
● Several studies revealed significantly positive associa-
tions between consumption of SSBs and the risk of
developing hypertension, while some showed no link
between SSBs and hypertension among school students.
The conclusions are conflicting.
● To date, there is no study reporting the relationship
between SSBs and school students’ hypertension in China,
despite the rapid economic growth and wide consumption
of SSBs in China, particularly in urban areas.
What this study adds
● In this study, we found a significantly positive
association between the consumption of SSBs and
hypertension among school students.
● SSBs may play a contributing role in developing
childhood hypertension in this population in China,
Sugar-sweetened beverages and school students’....
which has important implications for future population-
based childhood hypertension intervention in China.
Acknowledgements The study was supported by Nanjing Medical
Science and Technique Foundation (ZDX12019), China. Our special
thanks go to study participants and the school personnel that partici-
pated in the data collection.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
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