**1. Introduction**

High blood pressure is among the most important risk factors for cardiovascular disease (CVD), the leading cause of death in adults, and the fifth leading cause of death among those aged 15–24 years in the United States [1–3]. Based on cross-sectional data from the National Health and Nutrition Examination (NHANES) in 2013–2014, an estimated 31.6% of adults aged 18 years and older were hypertensive, which amounted to approximately 75.1 million adults. Only about half of these adults (53.9%) had their blood pressure under control [4], leaving them especially vulnerable to CVD and related health problems.

Hypertension is a critical public health issue that may originate to some extent in childhood or adolescence [1,5–8]. As an example, high blood pressure during adolescence is associated with persistent cardiovascular alterations that can continue into adulthood [1,7,8]. In addition, national survey data illustrate that approximately one in ten adolescents screen positive for elevated blood pressure across the United States. Based on NHANES data from 2011–2012, elevated blood pressure, defined as high or borderline, was reported for 11% of those aged 8–17 years [9]. The prevalence was higher among males (15.4%) versus females (6.8%), Hispanics (11.5%) and non-Hispanic blacks (15.3%) versus non-Hispanic whites (9.4%), and those 13 to 17 years of age (15.0%) versus those 8–12 years of age (6.5%) [9]. In 2017, the American Academy of Pediatrics put forth revised clinical practice guidelines as an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescent" [10]. Although the new guidelines are not a substantial departure from the prior report, applying the criteria to NHANES and other data suggests that more children would be classified as having elevated blood pressure and that shorter children aged 13 years and younger, and children over 13 years of age of any height may have a greater likelihood of being diagnosed as hypertensive [11,12]. Sharma and colleagues analyzed NHANES data from 1999–2014 and found that the prevalence of elevated blood pressure among children aged 5–18 years was 11.8% under the previous guidelines versus 14.2% under the revised guidelines [12].

Along with age, race and ethnicity, it is well known that socioeconomic status, lifestyle factors, nutrition, exercise, and body composition (e.g., excess body fat) play important roles in the occurrence and prevention of hypertension in adults [13–15]. A growing number of studies provide evidence that adolescents with elevated blood pressure also may be more likely to consume higher levels of sodium, lower levels of potassium, and more dietary fat; be less physically active; have poorer sleep quality; and be from lower socioeconomic levels [9,16–23]. However, the relationships between potential risk factors and the magnitude of their association with elevated blood pressure have not been established conclusively in younger populations.

Work-related factors are also consistently associated with hypertension in adults. Specific issues associated with increased blood pressure include job insecurity, long work hours, low wages, and jobs with poor work organization, as defined by jobs with high demands with low control or jobs that require considerable effort with low reward [24–28]. The exact mechanisms governing how these issues increase blood pressure is not entirely known. In adult workers, work stress may result in repeated activation of the autonomic nervous system, which can contribute to high blood pressure and heart disease based on studies with adult workers [29]. In addition, the time spent working may simply decrease the amount of time available for physical activity or other healthy behaviors (e.g., healthy diet). This may be especially true for adolescents who already contend with notable time demands, including attending school, participating in after school activities including team sports with considerable practice requirements, and helping with family chores and other obligations. Finally, work stress also may increase unhealthy coping behaviors such as excessive food consumption, consuming foods higher in sugar and saturated fat, or consuming alcohol. For example, a study found that fast food restaurant use among adolescents was associated with student employment, television usage, perceived barriers to healthy eating, and availability of unhealthy foods [30]. In addition, studies on working adolescents illustrate that long work hours contribute to the early onset of alcohol use [31–34].

The National Institute for Occupational Safety and Health (NIOSH) has recognized for over a decade that a variety of work-related exposures and issues influence overall health and well-being. From this perspective, whether and how work-related factors including stress, workload, and work hours influence health conditions (such as chronic disease) is as important as ensuring a safe workplace in a more traditional sense (e.g., minimizing physical hazards to address acute injuries). In 2011, NIOSH put forth the Total Worker Health Program to continue elevating this issue, spur further research, and promote workplace wellness programs [35]. In line with this holistic approach to worker health, the objective of the present study was to begin examining the relationship between current work status and elevated blood pressure in adolescents.
