Effect of Comprehensive Interventions Including Nutrition Education and Physical Activity on High Blood Pressure among Children: Evidence from School-Based Cluster Randomized Control Trial in China
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Intervention Measures
2.3. BP and Other Anthropometric Measurements
2.4. Sociodemographic Information and Food Consumption
2.5. Statistical Methods
3. Results
3.1. General Characteristics
3.2. Energy Expenditure and Food Consumption
3.3. Effects on BP
3.4. Relationship between BMI and BP
4. Discussion
5. Conclusions
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
- Kearney, P.M.; Whelton, M.; Reynolds, K.; Whelton, P.K.; He, J. Worldwide prevalence of hypertension: A systematic review. J. Hypertens. 2004, 22, 11–19. [Google Scholar] [CrossRef]
- Dong, B.; Wang, H.J.; Wang, Z.; Liu, J.S.; Ma, J. Trends in blood pressure and body mass index among Chinese children and adolescents from 2005 to 2010. Am. J. Hypertens. 2013, 26, 997–1004. [Google Scholar] [CrossRef] [Green Version]
- Falkner, B.; Lurbe, E.; Schaefer, F. High blood pressure in children: Clinical and health policy implications. Clin. Hypertens. 2010, 12, 261–276. [Google Scholar] [CrossRef]
- Lurbe, E.; Álvarez, J.; Redon, J. Diagnosis and treatment of hypertension in children. Curr. Hypertens. Rep. 2010, 12, 480–486. [Google Scholar] [CrossRef]
- Chen, X.; Wang, Y. Tracking of blood pressure from childhood to adulthood: A systematic review and meta-regression analysis. Circulation 2008, 117, 3171–3180. [Google Scholar] [CrossRef] [Green Version]
- Sorof, J.; Daniels, S. Obesity hypertension in children: A problem of epidemic proportions. Hypertension 2002, 40, 441–447. [Google Scholar] [CrossRef] [Green Version]
- Falkner, B. Hypertension in children and adolescents: Epidemiology and natural history. Pediatr. Nephrol. 2010, 25, 1219–1224. [Google Scholar] [CrossRef] [Green Version]
- Cheung, E.L.; Bell, C.S.; Samuel, J.P.; Poffenbarger, T.; Redwine, K.M.; Samuels, J.A. Race and obesity in adolescent hypertension. Pediatrics 2017, 139, e20161433. [Google Scholar] [CrossRef] [Green Version]
- Jafar, T.H.; Islam, M.; Hatcher, J.; Hashmi, S.; Bux, R.; Khan, A.; Poulter, N.; Badruddin, S.; Chaturvedi, N. Hypertension Research Group. Community based lifestyle intervention for blood pressure reduction in children and young adults in developing country: Cluster randomised controlled trial. BMJ 2010, 340, c2641. [Google Scholar] [CrossRef] [Green Version]
- Kelley, G.A.; Kelley, K.S.; Tran, Z.V. The effects of exercise on resting blood pressure in children and adolescents: A meta-analysis of randomized controlled trials. Prev. Cardiol. 2003, 6, 8–16. [Google Scholar] [CrossRef] [Green Version]
- Burke, V.; Beilin, L.J.; Milligan, R.; Thompson, C. Assessment of nutrition and physical activity education programmes in children. Clin. Exp. Pharm. Physiol. 1995, 22, 212–216. [Google Scholar] [CrossRef]
- Angelopoulos, P.D.; Milionis, H.J.; Grammatikaki, E.; Moschonis, G.; Manios, Y. Changes in BMI and blood pressure after a school based intervention: The CHILDREN study. Eur. J. Public Health 2009, 19, 319–325. [Google Scholar] [CrossRef] [Green Version]
- Ketelhut, S.; Ketelhut, S.R.; Ketelhut, K. School-Based Exercise Intervention Improves Blood Pressure and Parameters of Arterial Stiffness in Children: A Randomized Controlled Trial. Pediatr. Exerc. Sci. 2020, 2020, 1–7. [Google Scholar] [CrossRef]
- Xu, H.; Li, Y.; Zhang, Q.; Hu, X.; Liu, A.; Du, S.; Li, T.; Guo, H.; Li, Y.; Xu, G.; et al. Comprehensive school-based intervention to control overweight and obesity in China: A cluster randomized controlled trial. Asia Pac. J. Clin. Nutr. 2017, 26, 1139–1151. [Google Scholar]
- Li, Y.; Hu, X.; Zhang, Q.; Liu, A.; Fang, H.; Hao, L.; Duan, Y.; Xu, H.; Shang, X.; Ma, J.; et al. The nutrition-based comprehensive intervention study on childhood obesity in China (NISCOC): A randomized cluster controlled trial. BMC Public Health 2010, 10, 229. [Google Scholar] [CrossRef] [Green Version]
- Ma, G.; Hu, X. Healthy School, 1st ed.; Population Publisher: Beijing, China, 2009. [Google Scholar]
- Liu, A.; Hu, X.; Ma, G.; Cui, Z.; Pan, Y.; Chang, S.; Zhao, W.; Chen, C. Evaluation of a classroom-based physical activity promoting programme. Obes. Rev. 2008, 9, 130–134. [Google Scholar] [CrossRef]
- Mi, J.; Wang, T.; Meng, L.; Zhu, G.; Han, S.; Zhong, Y. Development of blood pressure reference standards for Chinese children and adolescents. Chin. J. Evid. Based Pediatr. 2010, 5, 4–14. [Google Scholar]
- Group of China Obesity Task Force. Body mass index reference norm for screening overweight and obesity in Chinese children and adolescents. Chin. J. Epidemiol. 2004, 25, 97–102. [Google Scholar]
- Farpour-Lambert, N.J.; Aggoun, Y.; Marchand, L.M.; Martin, X.E.; Herrmann, F.R.; Beghetti, M. Physical activity reduces systemic blood pressure and improves early markers of atherosclerosis in pre-pubertal obese children. J. Am. Coll. Cardiol. 2009, 54, 2396–2406. [Google Scholar] [CrossRef]
- Luepker, R.V.; Perry, C.L.; McKinlay, S.M.; Nader, P.R.; Parcel, G.S.; Stone, E.J.; Webber, L.S.; Elder, J.P.; Feldman, H.A.; Johnson, C.C. Outcomes of a field trial to improve children’s dietary patterns and physical activity. The Child and Adolescent Trial for Cardiovascular Health. CATCH collaborative group. JAMA 1996, 275, 768–776. [Google Scholar] [CrossRef]
- Mcmurray, R.G.; Harrell, J.S.; Bangdiwala, S.I.; Bradley, C.B.; Deng, S.; Levine, A. A school-based intervention can reduce body fat and blood pressure in young adolescents. J. Adolesc. Health 2002, 31, 125–132. [Google Scholar] [CrossRef]
- Lawes, C.M.; Vander Hoorn, S.; Rodgers, A. Global burden of blood-pressure-Related disease, 2001. Lancet 2008, 371, 1513–1518. [Google Scholar] [CrossRef]
- Aburto, N.J.; Ziolkovska, A.; Hooper, L.; Elliott, P.; Cappuccio, F.P.; Meerpohl, J.J. Effect of lower sodium intake on health: Systematic review and meta-analyses. BMJ 2013, 346, f1326. [Google Scholar] [CrossRef] [Green Version]
- Flynn, J.T.; Kaelber, D.C.; Baker-Smith, C.M.; Blowey, D.; Carroll, A.E.; Daniels, S.R.; de Ferranti, S.D.; Dionne, J.M.; Falkner, B.; Flinn, S.K.; et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics 2017, 140, e20171904. [Google Scholar] [CrossRef] [Green Version]
- Lurbe, E.; Agabiti-Rosei, E.; Cruickshank, J.K.; Dominiczak, A.; Erdine, S.; Hirth, A.; Invitti, C.; Litwin, M.; Mancia, G.; Pall, D.; et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J. Hypertens. 2016, 34, 1887–1920. [Google Scholar] [CrossRef] [Green Version]
- Falkner, B.; Gidding, S.S.; Ramirez-Garnica, G.; Wiltrout, S.A.; West, D.; Rap-paport, E.B. The relationship of body mass index and blood pressure in primary care pediatric patients. J. Pediatr. 2006, 148, 195–200. [Google Scholar] [CrossRef]
- Yang, Q.; Zhang, Z.; Kuklina, E.V.; Fang, J.; Ayala, C.; Hong, Y.; Loustalot, F.; Dai, S.; Gunn, J.P.; Tian, N.; et al. Sodium intake and blood pressure among US children and adolescents. Pediatrics 2012, 130, 611–619. [Google Scholar] [CrossRef] [Green Version]
- Damasceno, M.M.; de Araújo, M.F.; de Freitas, R.W.; de Almeida, P.C.; Zanetti, M.L. The association between blood pressure in adolescents and the consumption of fruits, vegetables and fruit juice—An exploratory study. J. Clin. Nurs. 2011, 20, 1553–1560. [Google Scholar] [CrossRef]
- Yun, M.; Li, S.; Sun, D.; Ge, S.; Lai, C.C.; Fernandez, C.; Chen, W.; Srinivasan, S.R.; Berenson, G.S. Tobacco smoking strengthens the association of elevated blood pressure with arterial stiffness: The Bogalusa Heart Study. J. Hypertens. 2015, 33, 266–274. [Google Scholar] [CrossRef] [Green Version]
- Wang, S.; Dong, Y.H.; Wang, Z.H.; Zou, Z.Y.; Ma, J. Trends in overweight and obesity among Chinese children of 7–18 years old during 1985–2014. Zhonghua Yu Fang Yi Xue Za Zhi 2017, 51, 300–305. (In Chinese) [Google Scholar]
- NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: A pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet 2017, 390, 2627–2642. [Google Scholar] [CrossRef] [Green Version]
- NCD Risk Factor Collaboration (NCD-RisC). Rising rural body-mass index is the main driver of the global obesity epidemic in adults. Nature 2019, 569, 260–264. [Google Scholar] [CrossRef] [Green Version]
- Su, C.; Wang, H.; Wang, D.; DU, W.; Zhang, J.; Ouyang, Y.; Jia, X.; Huang, F.; Zhang, B. The impact of community urbanization and household income on breakfast behaviors among Chinese children and adolescents in twelve provinces. Wei Sheng Yan Jiu 2016, 45, 882–887. (In Chinese) [Google Scholar]
Characteristics | Intervention or Control | Retained or Lost | ||
---|---|---|---|---|
Intervention Group | Control Group | Retained | Lost | |
No. of participants | 3431 | 3333 | 6764 | 906 |
Sex, girls # (n (%)) | 1693 (49.3) | 1648 (49.4) | 3341 (49.4) | 438 (48.3) |
Overweight/obese # (n (%)) | 905 (26.4) | 826 (24.8) | 1731 (25.6) | 223 (24.6) |
DBP † (mm Hg, (Mean (SD)) | 62.5 (9.3) | 62.4 (9.1) | 62.5 (9.2) | 61.1 (9.0) |
SBP † (mm Hg, (Mean (SD)) | 99.2 (11.0) | 99.0 (11.3) | 99.1 (11.1) | 97.1 (11.3) |
High BP # (n (%)) | 360 (10.5) | 368 (11.0) | 728 (10.8) | 73 (8.1) |
Age † (years, (Mean (SD)) | 9.1 (1.4) | 9.1 (1.4) | 9.1 (1.4) | 9.1 (1.4) |
Children ≤ 10 years old # (n (%)) | 3092 (90.1) | 3016 (90.5) | 6108 (90.3) | 802 (88.5) |
Parental educational level # (n (%)) | ||||
Low (illiterate) | 6 (0.2) | 11 (0.4) ** | 17 (0.3) | 2 (0.3) * |
Middle (primary or junior middle school) | 889 (33.3) | 1020 (39.8) | 1909 (36.4) | 191 (33.2) |
High (senior middle school or above) | 1777 (66.5) | 1530 (59.7) | 3307 (63.3) | 382 (66.4) |
Family’s income level (yuan/month/per capita) # (n (%)) | ||||
≤1500 | 1094 (41.0) | 1160 (45.3) ** | 2254 (43.1) | 235 (40.9) * |
1501–2500 | 756 (28.4) | 683 (26.7) | 1439 (27.7) | 154 (26.8) |
>2500 | 816 (30.6) | 715 (28.0) | 1531 (29.1) | 186 (32.3) |
Variables | Control Group | Intervention Group | p-Value | ||
---|---|---|---|---|---|
Baseline | Change | Baseline | Change | ||
Energy expenditure (Kcal/day, mean (SD)) | 236 (128.9) | 63.5 (129.9) | 224.9 (131.4) | 77.0 (149.1) | 0.967 |
Cereals (>3 times/3 days, n (%)) | 1324 (80.8) | −205 (−12.5) | 1337 (78.1) | −105 (−6.1) | 0.005 |
Meat (>3 times/3 days, n (%)) | 1001 (61.1) | −14 (−0.9) | 1098 (64.1) | 75 (4.4) | 0.018 |
Vegetables (>3 times/3 days, n (%)) | 1099 (67.1) | −15 (−1.0) | 1168 (68.2) | −20 (−1.1) | 0.883 |
Fruits (≥1 time/3 days, n (%)) | 765 (46.7) * | −65 (−4.0) | 741 (43.3) | 84 (4.9) | 0.000 |
Dairy (≥1 time/3 days, n (%)) | 1124 (68.6) | −94 (−5.8) | 1217 (71.1) | −85 (−5.0) | 0.705 |
Eggs (≥1 time/3 days, n (%)) | 1223 (74.6) | 59 (3.6) | 1314 (76.8) | 11 (0.6) | 0.169 |
Fish and shellfish (≥1 time/3 days, n (%)) | 927 (56.6) * | −55 (−3.4) | 1041 (60.8) | −157 (−9.2) | 0.013 |
Fungi and algae (≥1 time/3 days, n (%)) | 600 (36.6) | −15 (−0.9) | 603 (35.2) | −10 (−0.6) | 0.850 |
Dried legumes (≥1 time/3 days, n (%)) | 874 (53.3) ** | 48 (3.0) | 1018 (59.5) | −197 (−11.5) | <0.001 |
Nuts and seeds (≥1 time/3 days, n (%)) | 284 (17.3) | −61 (−3.7) | 215 (12.6) | −57 (−3.4) | 0.514 |
Snack (≥1 time/3 days, n (%)) | 305 (18.6) | −39 (−2.4) | 313 (18.3) | −48 (−2.8) | 0.764 |
Fast foods (≥1 time/3 days, n (%)) | 1145 (69.9) | −113 (−6.9) | 1178 (68.8) | −97 (−5.7) | 0.579 |
Beverages (≥1 time/3 days, n (%)) | 586 (35.8) ** | −184 (−11.3) | 527 (30.8) | −156 (−9.1) | 0.420 |
Sugars and preserves (≥1 time/3 days, n (%)) | 404 (24.6) ** | −64 (−3.9) | 353 (20.6) | −33 (−1.9) | 0.669 |
Intervention Group | Control Group | Intervention Effect | ||||
---|---|---|---|---|---|---|
Groups | Baseline (Mean ± SD) | Change (Mean ± SD) | Baseline (Mean ± SD) | Change (Mean ± SD) | Beta (95%CI) | p-Value |
DBP | ||||||
Total | 62.5 ± 9.3 | 1.3 ± 11.7 ** | 62.4 ± 9.1 | 1.8 ± 11.4 ** | −0.5 (−1.1, 0) | 0.064 |
High BP at baseline | 77.5 ± 8.3 | −10.6 ± 12.6 ** | 76.4 ± 8.4 | −8.1 ± 12.8 ** | −2.4 (−4.3, −0.6) | 0.010 |
Non-high BP at baseline | 60.8 ± 7.7 | 2.7 ± 10.8 ** | 60.7 ± 7.6 | 3.0 ± 10.6 ** | −0.4 (−0.9, 0.2) | 0.186 |
p-value for interaction | <0.001 | |||||
Overweight/obese at baseline | 65.8 ± 9.9 | 0.3 ± 12.7 | 65.1 ± 9.9 | 2.2 ± 12.2 ** | −1.9 (−3.1, −0.7) | 0.002 |
Non-overweight/obese at baseline | 61.4 ± 8.9 | 1.6 ± 11.4 ** | 61.5 ± 8.7 | 1.7 ± 11.2 ** | 0 (−0.7, 0.6) | 0.903 |
p-value for interaction | <0.001 | |||||
Boys | 62.5 ± 9.0 | 1.9 ± 11.4 ** | 62.2 ± 9.0 | 2.4 ± 11.1 ** | −0.4 (−1.2, 0.3) | 0.275 |
Girls | 62.6 ± 9.7 | 0.6 ± 12.1 * | 62.6 ± 9.3 | 1.2 ± 11.8 ** | −0.6 (−1.4, 0.2) | 0.127 |
p-value for interaction | <0.001 | |||||
Children ≤ 10 years | 62.3 ± 9.3 | 1.0 ± 11.7 ** | 62.0 ± 9.0 | 1.8 ± 11.4 ** | −0.7 (−1.3, −0.2) | 0.012 |
Children > 10 years | 64.4 ± 9.5 | 3.7 ± 11.8 ** | 66.4 ± 9.4 | 2.2 ± 12.0 ** | 1.4 (−0.4, 3.3) | 0.123 |
p-value for interaction | <0.001 | |||||
SBP | ||||||
Total | 99.2 ± 11.0 | 1.9 ± 12.2 ** | 99.0 ± 11.3 | 2.7 ± 13.0 ** | −0.9 (−1.5, −0.3) | 0.005 |
High BP at baseline | 116.6 ± 8.8 | −8.6 ± 12 ** | 117.1 ± 9.6 | −8.7 ± 12.8 ** | 0.1 (−1.7, 2.0) | 0.874 |
Non-high BP at baseline | 97.1 ± 9.3 | 3.1 ± 11.6 ** | 96.7 ± 9.2 | 4.1 ± 12.2 ** | −1.1 (−1.7, −0.5) | 0.001 |
p-value for interaction | <0.001 | |||||
Overweight/obese at baseline | 104.4 ± 11.3 | 1.9 ± 13.1 ** | 104.4 ± 12.6 | 3.4 ± 14.4 ** | −1.5 (−2.8, −0.2) | 0.026 |
Non-overweight/obese at baseline | 97.3 ± 10.2 | 1.9 ± 11.8 ** | 97.2 ± 10.2 | 2.5 ± 12.4 ** | −0.7 (−1.3, 0) | 0.056 |
p-value for interaction | <0.001 | |||||
Boys | 100.2 ± 10.9 | 2.0 ± 12.2 ** | 100.2 ± 11.3 | 2.7 ± 12.8 ** | −0.7 (−1.5, 0.2) | 0.118 |
Girls | 98.1 ± 11.0 | 1.7 ± 12.2 ** | 97.7 ± 11.1 | 2.8 ± 13.1 ** | −1.0 (−1.9, −0.2) | 0.017 |
p-value for interaction | <0.001 | |||||
Children ≤ 10 years | 98.9 ± 10.9 | 1.6 ± 12 ** | 98.6 ± 11.2 | 2.4 ± 12.8 ** | −0.8 (−1.4, −0.1) | 0.016 |
Children > 10 years | 101.6 ± 11.1 | 4.3 ± 13.6 ** | 102.7 ± 11.5 | 6.1 ± 13.7 ** | −1.9 (−3.9, 0.2) | 0.083 |
p-value for interaction | <0.001 |
Groups | Intervention Group | Control Group | Intervention Effect | |||
---|---|---|---|---|---|---|
Baseline (n (%)) | Change (n (%)) | Baseline (n (%)) | Change (n (%)) | Beta (95%CI) | p-Value | |
Total | 392 (10.0) | −55 (−1.4) | 409 (10.9) | 17 (0.4) * | −0.2 (−0.5, 0) | 0.015 |
Non-high BP at baseline | 0 (0) | 251 (7.1) ** | 0 (0) | 321 (9.6) ** | −0.3 (−0.5, −0.1) | <0.001 |
High BP at baseline | 392 (100) | −306 (−78.1) ** | 409 (10.9) | −304 (−74.3) ** | −0.2 (−0.5, 0.1) | 0.207 |
p-value for interaction | 0.576 | |||||
Non-overweight/obese | 180 (6.3) | −16 (−0.6) | 205 (7.2) | −1 (0) | −0.1 (−0.4, 0.1) | 0.347 |
Overweight/obese | 212 (20.4) | −39 (−3.7) | 204 (22.3) | 18 (2.0) * | −0.4 (−0.7, −0.1) | 0.009 |
p-value for interaction | <0.001 | |||||
Boys | 178 (9) | −2 (−0.1) | 193 (10.1) | 12 (0.7) | −0.1 (−0.4, 0.2) | 0.470 |
Girls | 214 (11.1) | −53 (−2.7) * | 216 (11.6) | 5 (0.3) | −0.4 (−0.7, −0.1) | 0.007 |
p-value for interaction | 0.021 | |||||
Children ≤ 10 years | 358 (10.2) | −50 (−1.4) | 372 (11.0) | 2 (0) | −0.2 (−0.4, 0) | 0.055 |
Children > 10 years | 34 (8.7) | −5 (−1.3) | 37 (10.1) | 15 (4.1) ** | −0.6 (−1.3, 0.1) | 0.076 |
p-value for interaction | 0.003 |
Variables | Intervention Group | Control Group | ||
---|---|---|---|---|
β1 | p-Value | β1 | p-Value | |
DBP-C | 0.24 | 0.034 | 0.28 | 0.033 |
SBP-C | 0.47 | <0.001 | 0.72 | <0.001 |
Models | Intervention Group | Control Group | ||
---|---|---|---|---|
β1 | p-Value | β1 | p-Value | |
DBP-C | ||||
Model 1 | 0.22 | 0.053 | 0.27 | 0.041 |
Model 2 | 0.48 | <0.001 | 0.75 | <0.001 |
Model 3 | 0.67 | <0.001 | 0.68 | <0.001 |
SBP-C | ||||
Model 4 | 0.50 | <0.001 | 0.70 | <0.001 |
Model 5 | 0.71 | <0.001 | 1.29 | <0.001 |
Model 6 | 1.05 | <0.001 | 1.22 | <0.001 |
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Xu, H.; Li, Y.; Shang, X.; Du, S.; Zhang, Q.; Liu, A.; Ma, G. Effect of Comprehensive Interventions Including Nutrition Education and Physical Activity on High Blood Pressure among Children: Evidence from School-Based Cluster Randomized Control Trial in China. Int. J. Environ. Res. Public Health 2020, 17, 8944. https://doi.org/10.3390/ijerph17238944
Xu H, Li Y, Shang X, Du S, Zhang Q, Liu A, Ma G. Effect of Comprehensive Interventions Including Nutrition Education and Physical Activity on High Blood Pressure among Children: Evidence from School-Based Cluster Randomized Control Trial in China. International Journal of Environmental Research and Public Health. 2020; 17(23):8944. https://doi.org/10.3390/ijerph17238944
Chicago/Turabian StyleXu, Haiquan, Yanping Li, Xianwen Shang, Songming Du, Qian Zhang, Ailing Liu, and Guansheng Ma. 2020. "Effect of Comprehensive Interventions Including Nutrition Education and Physical Activity on High Blood Pressure among Children: Evidence from School-Based Cluster Randomized Control Trial in China" International Journal of Environmental Research and Public Health 17, no. 23: 8944. https://doi.org/10.3390/ijerph17238944