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Year : 2019  |  Volume : 22  |  Issue : 8  |  Page : 1140-1146

Hypertension and its risk factors among male adolescents in intermediate and secondary schools in Sakaka City, Aljouf Region of Saudi Arabia

1 Department of Family and Community Medicine, College of Medicine, Jouf University, Sakaka, Saudi Arabia; Department of Community Medicine, SK. Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
2 College of Medicine, Jouf University, Sakaka, Saudi Arabia

Date of Acceptance10-Apr-2019
Date of Web Publication14-Aug-2019

Correspondence Address:
Dr. A Bandy
Department of Family and Community Medicine, College of Medicine, Jouf University, PO Box 2014, Sakaka; Department of Community Medicine, SK. Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_507_18

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Objective: Hypertension among adolescents is an emerging public health problem. The current study aims to estimate the burden of hypertension and identify its risk factors among male adolescents of intermediate and secondary schools. Subjects and Methods: This is a school-based cross-sectional study that targeted 400 male adolescents in the age group of 15–17 years. Blood pressure was defined as per the “Fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents”. An electronic device approved for use by the European Society of Hypertension International Protocol revision 2010, (Omron M3W; HEM-7202-E) was used for measuring blood pressure. CDC's body mass index tool was adopted for defining overweight and obesity. Descriptive analysis for hypertension and the risk factors were carried out. Chi-square test and odds ratios were calculated to assess any association between categorical variables. Results: Overall 36 (9.0%) adolescents had prehypertension and 69 (17.2%) had hypertension. Systolic prehypertension, systolic hypertension, diastolic prehypertension, and diastolic hypertension were present in 6.5%, 17.2%, 5.8%, and 9.0% of the adolescents, respectively. Bivariate analysis revealed that overweight and obesity, no physical activity, or once-a-week physical activity, positive family history of hypertension, and smoking were predictors of systolic prehypertension and showed a significant relationship with systolic hypertension. Conclusion: There is a considerable prevalence of prehypertension and hypertension, among school-going male adolescents. We recommend school-based health education programs and routine screening directed toward the risk factors of noncommunicable diseases like hypertension with special attention to obesity, physical inactivity, and smoking.

Keywords: Hypertension, male adolescents, risk factors

How to cite this article:
Bandy A, Qarmush M M, Alrwilly A R, Albadi A A, Alshammari A T, Aldawasri M M. Hypertension and its risk factors among male adolescents in intermediate and secondary schools in Sakaka City, Aljouf Region of Saudi Arabia. Niger J Clin Pract 2019;22:1140-6

How to cite this URL:
Bandy A, Qarmush M M, Alrwilly A R, Albadi A A, Alshammari A T, Aldawasri M M. Hypertension and its risk factors among male adolescents in intermediate and secondary schools in Sakaka City, Aljouf Region of Saudi Arabia. Niger J Clin Pract [serial online] 2019 [cited 2021 Aug 5];22:1140-6. Available from:

   Introduction Top

Hypertension is the commonest noncommunicable disease that affects the adult population of both genders and continues to be a leading risk factor for cardiovascular and cerebrovascular diseases.[1] In children, hypertension may progress into adult life, thus increasing the risks of cardiovascular events in later life.[2],[3] A slight increase in blood pressure can lead to organ damage if left untreated. The onset of hypertension at a young age reduces the lifespan if no treatment is initiated at this stage.[4] A clustering effect on metabolic syndrome factors has been observed among adolescents with hypertension.[5]

Studies on hypertension across the world have mainly focused on the middle-aged and elderly population.[6],[7],[8] As a result of this perception of hypertension being a disease of adults and elderly, a young individual's reaction is of disbelief when diagnosed with hypertension.[8] Healthcare professionals caring for adolescents have also underdiagnosed hypertension in the young.[9] Other studies across the world have shown coexistence of hypertension with a list of other conditions like insulin resistance and obesity, among adolescents.[10],[11],[12] Evidences of increasing number of adolescent hypertensive population are accumulating.[9],[13],[14]

In some developed countries, prevalence of pediatric hypertension varied from 3.6% to 4.2 percent.[9],[15] In their cross-sectional study, Benedicta et al. reported a 22.0% and 13.6% prevalence of hypertension and prehypertension, respectively, among male adolescents aged 13–17 years.[16] Kemp et al. reported a prevalence of 8.5% of prehypertension and 24.9% of hypertension among South African grade-1 pupils.[17] Studies from India reported 5% of children suffer from hypertension, whereas, 4.9% of prehypertension and 4.9% hypertension has been reported from Sudan.[18],[19] A study that was aimed at establishing representative blood pressure reference centiles for Saudi Arabian children and adolescents observed that the annual increase of systolic blood pressure was 1.66 mmHg for boys and 1.44 mmHg for girls. Diastolic blood pressure showed a sharp increase at the age of 18 years.[20] Another study conducted in 2015 in the Eastern province of Saudi Arabia showed that 30% of the adolescent study population had systolic hypertension while 20% had diastolic hypertension. This study also highlighted that the systolic blood pressure among girls aged 13–16 years was higher than the 95th percentile for Saudi national norms thereby highlighting a possible regional variation in blood pressure.[21]

Identifying at-risk children is important for primordial and primary prevention of hypertension by focusing on the risk factors that include physical inactivity, smoking, positive family history, and obesity among many others.[22] Estimating the burden of hypertension and identification of risk factors of hypertension is a prerequisite for developing effective prevention programs for hypertension and its sequelae. The current study was undertaken to uncover the burden of hypertension and identify risk factors for hypertension among male adolescents of intermediate and secondary schools of Sakaka city of Aljouf region.

   Material and Methods Top

Design, setting, and participants

This is a cross-sectional, school-based study that included male adolescents in the age group of 15–17 years, apparently healthy and free from any noncommunicable disease, from intermediate and secondary schools. The age of students in the intermediate and secondary schools ranges from 12–15 and 16–18 years, respectively. A feasibility study revealed that covering both genders was not possible due to cultural barriers. The study was carried out between January 2018 and March 2018.

Sample size and sampling procedure

The sample size was calculated using Epi Info software. As no other study on prevalence of hypertension was available in this region, researchers guesstimated a 50% prevalence of hypertension among school-going adolescents for calculating the sample size. At 95% level of confidence with 5% margin of error, the minimum number of adolescents required to carry out this study was 384. Male students in the age group of

15–17 years were included in the study. Students with a history of hypertension, diabetes, and heart and kidney diseases were excluded. A multistage sampling procedure was followed to arrive at the sample size. The sample was collected from secondary and intermediate schools based on population proportion to size (PPS). Number of students in each class was ascertained and students from each stratum were selected using systematic random sampling. The sampling procedure is explained in the [Figure 1].
Figure 1: Sampling scheme

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Tool for data collection

A validated questionnaire in the local language was used to collect data on the demography and various risk factors. The questionnaire was pretested on 30 students to ensure reliability and internal consistency. The questionnaires were sent to the parents of selected candidates a day before taking the anthropometric measurements of the students. SPSS was used to calculate Cronbach's alpha from the data collected on these 30 students. A Cronbach's alpha reliability score of 0.79 was obtained which falls in the acceptable range. However, these students were excluded from the final analysis.

   Measurements Top

Students were advised to wear loose and light clothing on the subsequent school day for taking the blood pressure and anthropometric measurements. The selected students were assembled before teaching sessions or during break between teaching sessions for taking the measurements.

Bathroom digital scale was used for measuring weight after removing the shoes. Height was measured by a portable stadiometer. Students were asked to remove shoes, head was held erect with buttocks, shoulder blades and heel touching the scale and arms hanging naturally by the side. The standing height was measured to the nearest 0.5 cm and body weight to the nearest 0.1 kg on a digital scale. Weight and height were measured as per WHO STEPwise approach to chronic disease risk factor surveillance manual.[23] The cutoff points of the Centre for Disease Control and Prevention (CDC) for this age group were used in the assessment of obesity and overweight. The CDC tool for BMI calculations was used for calculating BMI of each student.[24] Body mass indices falling between the 5th and <85th percentile were considered normal, ≥85th percentile to <95th percentile as overweight, and ≥95th percentile were considered obese.

Participants were asked to relax in the assembly room for half an hour; the arm was supported at the heart level, mean of the three measurements was taken as the final blood pressure for each participant with a gap of 10 minutes between each measurement. An electronic device (Omron M3W; HEM-7202-E, OMRON Healthcare Co., Ltd, Kyoto, Japan) was used for the measurement of blood pressure. The same model has been recommended by the European Society of Hypertension International Protocol revision 2010.[25] Blood pressure was defined as per the “Fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents”.[26] Online British Medical Journal best practice calculator was used to categorize the students' blood pressure percentiles.[27] Students' blood pressure percentiles are based on age and height percentiles.

Systolic blood pressure percentile interpretation.

Diastolic blood pressure percentile interpretation.

   Statistical Methods Top

Statistical package for social sciences (SPSS) for Windows version 20.0 (IBM SPSS Statistics, IBM Corporation, Armonk, NY, USA) was used for data analysis. Descriptive statistics were carried out to present demographic characteristics. Chi-squared test was used as a test of significance to compare categorical variables. Odds ratio along with confidence interval was calculated in Bivariate analysis.

Ethical approval

The local bioethical committee of Jouf University approved the study protocol vide letter no: HAP-13-S-001 dated December-2017. A proper permission was sought from the school administration before data collection. Data was collected after obtaining informed consent from parents. Students with high blood pressure results were referred to the school counselor for follow-ups.

   Results Top

This cross-sectional study targeted 400 adolescent students of intermediate and secondary schools. There were 251 (62.75%) adolescents from intermediate and 149 (37.25%) from secondary schools. Overweight and obesity was observed in 80 (20%) and 134 (33.5%) students, respectively. A total of 159 (39.8%) students were carrying out no or once-a-week physical activity, 184 (46%) had a positive family history of hypertension, and 102 (25.5%) were smokers as depicted in [Table 1].
Table 1: Demographic characteristics of study population (n=400)

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[Table 2] presents the prevalence of prehypertension, systolic and diastolic hypertension. Overall, 36 (9%) adolescents had prehypertension and 69 (17.25%) had hypertension. Systolic prehypertension and systolic hypertension were present in 26 (6.5%) and 69 (17.25%) of the adolescents, respectively. Diastolic prehypertension and diastolic hypertension were present in 23 (5.8%) and 36 (9%) adolescents, respectively.
Table 2: Prevalence of hypertension among study population (n=400)

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The bivariate analysis of systolic prehypertension and various demographic characteristics showed that overweight and obesity (P = 0.00; OR = 7.34 (2.18–24.88)), absence of physical activity or once-a-week physical activity (P = 0.01; OR = 2.58 (1.14–5.85)), positive family history of hypertension (P = 0.03; OR = 2.51; CI = 1.14–5.51), and smoking (P = 0.00; OR = 3.79; CI = 1.69–8.49) were predictors of systolic pre-hypertension. Similarly, all the studied demographic characteristics were predictors of systolic hypertension [Table 3].
Table 3: Relationship between Systolic prehypertension, systolic hypertension, and risk factors

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Bivariate analysis of demographic characteristics and diastolic prehypertension showed that overweight and obesity (P = 0.00; OR = 4.12 (1.48–13.27)), no physical activity or once a week physical activity (P = 0.01; OR = 3.03; CI = 1.25–7.33), and smoking (P = 0.01; OR = 2.81 (1.22–6.75) were predictors of diastolic prehypertension, whereas overweight and obesity and smoking history were the only two risk factors that were significantly present in higher proportions among participants having diastolic hypertension [Table 4].
Table 4: Relationship between diastolic prehypertension, diastolic hypertension, and risk factors

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   Discussion Top

Hypertension among adolescents is emerging as a major public health problem. Regular screening of hypertension in this age group is the cornerstone in preventing the emergence of complications in later life. To develop an effective prevention program an understanding of the magnitude of the problem and its correlates is essential.

The prevalence of prehypertension in this study is lower compared to the reports from South Africa and Houston.[16],[28] This variation in prevalence of prehypertension among adolescents could be a result of different population-based characteristics such as the age ranges in these studies. The prevalence of systolic hypertension in the current study is also less than the study by Alkahtani et al. that has reported a prevalence of 30% of systolic hypertension among intermediate and secondary school adolescents in the Eastern province of Saudi Arabia.[21] Current study noted a higher prevalence of both systolic and diastolic prehypertension and hypertension among secondary school adolescents compared to intermediate school adolescents, these finding run in conformity with the study by Alkahtani et al.[21] Hypertension among these adolescents can progress into adulthood and may increase their risk of cardiovascular events in later life. These findings highlight the importance of sensitizing primary healthcare physicians to screen adolescents for hypertension during the routine heath care visits. Under diagnosis of hypertension at younger age coupled with failure to initiate the treatment may shorten life expectancy as reported previously.[4]

Our study highlights the importance of normal weight and good physical activity in regulation of blood pressure. We found obesity, overweight, and lack of physical activity as risk factors for systolic and diastolic prehypertension and hypertension. A number of studies worldwide have shown that increased body mass index is associated with hypertension.[16],[29],[30],[31],[32],[33],[34] Oduwole et al. reported obesity as a strong predictor of diastolic hypertension in adolescent males.[35] The current study emphasises on reducing overweight and improving physical activity among adolescents. Students should be motivated to increase their physical activity and reduce weight. They should be educated on balanced diet. Physical activity and balanced diet are well-known factors in the prevention of obesity and hypertension.[36] The Office Of Disease Prevention And Health Promotion of America in their recent guidelines on physical activity recommend 60 minutes or more of moderate to vigorous physical activity on a daily basis among adolescents.[37]

We identified smoking as a modifiable risk factor that may have caused hypertension in our sampled population. These adolescents may continue smoking in their adulthood predisposing them to a range of other deleterious effects. The study highlights the need for life style modification by counseling and behavioral change. Furthermore, adolescents with a positive family history of hypertension were at an increased risk of developing hypertension. These findings are in agreement with a previous study by Qaddumi and his colleagues.[36]

The results should be interpreted with few limitations. The limitations include the restriction of study participants to male adolescents, the narrow age range of participants (15–17 years), and the omission of secondary causes/risk factors of hypertension such as DM, endocrinal causes, vascular causes, and the use of medications and salt intake. We recommend the inclusion of secondary causes, role of dietary habits in future studies on hypertension among adolescents in this region. Furthermore, research is needed to assess other metabolic syndrome components such as hyperlipidemia, insulin resistance/prediabetes among adolescents in the region.

   Conclusions Top

There is a high prevalence of both systolic and diastolic prehypertension and hypertension among school-going male adolescents aged 15–17 years. We recommend that more attention should be given to school-based health education programs directed to risks factors of noncommunicable diseases with special attention on obesity, physical inactivity, and smoking. Our study highlights the need for performing routine blood pressure check among school going adolescents.


The authors thank the school administration for arranging the session for carrying out the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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