*2.8. Preventive Strategies for Hypertension in Children*

There is limited literature regarding preventive strategies or intervention in children and adolescents with elevated blood pressure focusing on BP as the major end point [101,150]. In most cases, the main risk factor for HTN—increased body mass/fat mass is being targeted [2,101]. Similarly, there is limited evidence on population based primary prevention strategies in healthy children to reduce the future risk of HTN [2].

There are well established risk factors for developing HTN in children and adolescents. The major risk is overweight and obesity, additionally the nutritional scheme (quality and quantity of macronutrients), the amount of PA time (as a marker of CRF), parental-factors, sedentary/screen time and sleep time can independently increase prevalence of abnormal BP [151,152].

According to the Nuffield public health intervention ladder and it's modifications, the interventions can be made on different level of individual or population impact [153]. Prevention strategies can be divided into three main groups: individual/family-based, local-community-based and nationally-based activities. Most of those actions are universal for all non-communicable diseases (NCD's) or NCD's risk factors.

Individual, family and school-based level interventions should be mainly focus on education on pro-health behaviors and building ability and capacity/consciousness to put PA and health-supporting diet as one of priorities. There is limited evidence on this in HTN yet similar activities are effective in increased body mass/fat interventions [154,155]. For example, as presented by Farpour-Lambert et al., even 3 months of regular PA can decrease SBP by 7–12 mmHg and DBP by 2–7 mmHg. Others reported similar or smaller effects of SBP/DBP reduction of 2–8 mmHg during different time of intervention or observation time [155–158].

On local/community level policy makers need to focus on the availability of healthy nutritional options, and the availability and places to perform PA (playing fields, recreational areas, biking lanes, etc.) [159]. Additionally, professional trainers support in different sports availability to children during/after school increases their PA hours during the week [160–162], as well as building availability for healthy food choices at schools by limiting vending machines, and improving quality and availability of healthy food at cafeterias/canteens [163–166].

National preventing strategies should focus on the availability of healthy nutritional choices, e.g., through taxation policies, products formulas modification (ex. reducing sodium) [167–170], education campaigns build and delivered for separate age groups, and supporting local authorities in building healthy environments [171,172].

The effectiveness of single strategies/activities is usually limited or low from the clinical perspective, yet addition of several multi-level activities can importantly influence the burden of CVD in children/youth as well as future costs—both health and economic [101,152,173].
