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Confronting Pediatric Hypertension
By Heather Davis, MS, RDN, LDN
Hypertension (HTN) is a condition typically associated with adults, so it might come as a surprise to learn that HTN in youth is on the rise.1 A diagnosis of HTN in childhood can predict early onset CVD and other serious health conditions later in life, making prevention, early detection, and proper intervention critical. Although nutrition strategies can be highly effective in both preventive care and HTN management, many may wonder if there are differences in how clinicians ought to approach this condition in children compared with adults.
Kids vs Adults
In contrast to adults, there is a lack of high-quality peer-reviewed studies examining the effects of HTN interventions in the pediatric population. This may lead some to question whether there’s sufficient evidence to support interventions more common in adult populations, such as the well-known DASH diet, and if there are special considerations for pediatric HTN.
In a recently published paper from 2024, the authors sought to answer many of these questions by reviewing the latest evidence on specific nutrients, dietary patterns, and public health strategies that may help manage blood pressure (BP) in the pediatric population. They conducted a narrative review across several databases targeting meta-analyses, systematic reviews, randomized clinical trials, and observational studies worldwide. They also included data from scientific organizations such as the World Health Organization and the European Food Safety Authority.1 Here, we’ll reveal their findings, alongside related research, and share what it means for nutrition experts.
Dietary Advice
Several dietary patterns were explored in the review, including the DASH diet, plant-based diets (PBDs), the New Nordic diet (NND), and the Mediterranean diet (MedDiet).1 Due to the strong connection in both adult and pediatric populations between body weight—particularly obesity—and HTN, many of these approaches were evaluated based on their ability to directly impact BP, as well as how they may indirectly impact BP through influencing weight.
Pediatric obesity is an increasing public health concern that not only influences adult-onset risk for diseases like diabetes and CVD but also can increase risk for CVD even in adolescence.1 An abundance of research exists in effort to successfully navigate obesity prevention in children through diet and physical activity.2,3 Many multicomponent and multi-setting childhood obesity programs, including ones focused on dietary and physical activity interventions, seem to yield positive effects on BP as well.1
General Dietary Patterns
Current clinical practice guidelines advocate for a DASH diet for BP management in youth.1 A 2021 randomized controlled trial conducted by Couch et al evaluated the effects of a six-month DASH diet-focused behavioral nutrition intervention on BP and endothelial function in adolescents with elevated BP. The results showed that the DASH group had significant improvements in systolic BP, endothelial function, and diet quality immediately postintervention and at the 18-month follow-up compared with those receiving routine care.1 Other randomized controlled trials have shown similar results, additionally reducing diastolic BP in adolescents.1 The research is a bit conflicted regarding whether the DASH diet can result in weight loss, with some studies showing that reductions in BP may have occurred independently and others showing that these variables were more strongly connected.
By comparison, there is less research exploring the impact of the MedDiet on BP in kids. However, the existing data suggests a relationship between high adherence to a MedDiet in children and adolescents and lower BP values, with authors noting different responses depending on the genetic makeup of each individual.1
There is some compelling preliminary data suggesting the NND may also help reduce BP in children. In a prospective randomized controlled trial— Special Turku Coronary Risk Factor Intervention Project (n = 877 children)— dietary counseling based on the Nordic Nutrition Recommendations was provided. After 20 years of follow-up, achieving a higher number of dietary targets was linked to lower systolic BP.1
Several cross-sectional studies have analyzed the impact of different types of PBDs on body weight, macronutrient intake, and lipid profile. From these, it was shown that a PBD may improve body weight and lipid profile. However, some macro- and micronutrient deficiencies (mainly 25-hydroxy vitamin D, serum iron, and vitamin B12) are observed in children following a vegan PBD and this is the reason why the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition does not recommend a vegan diet for the pediatric population, but emphasizes that if a parent chooses to wean an infant onto a vegan diet, this should be performed under regular medical and expert dietetic supervision.1 Where BP in children is concerned, two prospective randomized trials showed the efficacy of PBDs in lowering BP in children and adolescents, both conducted by Macknin et al in 2015 and 2021, respectively. In one, participants included 96 adolescents with obesity and hypercholesterolemia whose CVD risk factors were evaluated through three different dietary patterns: PBD, in which daily vitamins B12 and D were supplemented; MedDiet; and an American Heart Association-advised healthy diet. The results showed similar statistically significant improvements in all metabolic markers, including reductions in LDL-C and total cholesterol plasma levels, weight, and systolic and diastolic BP.1
The authors point out that although these dietary patterns may come from different geographical and cultural regions, they can be generally characterized by a balanced intake of fruits, vegetables, whole grains, fish, eggs, and nuts.
Nutrients of Interest
One of the most important and well-documented nutrients impacting BP is, of course, sodium. However, over the years of research evaluating the relationship between sodium and BP, we know that potassium may be equally deserving of emphasis. The relative potassium deficiency in relation to the amount of sodium seems to be more of a causal factor for HTN than the absolute amount of sodium in the diet. Although there are recommendations for adequate intake (AI) of sodium and potassium for children, it is important to remember that the data used to develop them does not come from focused pediatric experiments, but is extrapolated from recommendations for adults.1
In 2019, the National Academies of Sciences, Engineering, and Medicine (NASEM) (formerly the Institute of Medicine) Committee to Review the Dietary Reference Intakes for Sodium and Potassium updated the definition of the tolerable upper level (UL). Previously, the UL was defined as “the highest level of nutrient intake that is likely to pose no adverse health effects for nearly all people in a particular group.” To further define “adverse health effects,” the committee currently characterizes the UL as “toxicological risk.” They also developed a new term, the “chronic disease risk reduction” (CDRR) intake for sodium, to describe the “intake above which intake reduction is expected to reduce chronic disease risk within an apparent healthy population.”4
Both the NASEM and the World Health Organization have established guidelines for sodium intake. For infants aged 0 to 6 months, the AI for sodium is 110 mg/day, based on the amounts found in breast milk. The AI for older infants (7 to 12 months) is 370 mg/day, as determined by estimating the sodium content of breast milk and complementary foods. The range encompassing the AI and CDRR for children and youth aged 1 to 18 years was extrapolated from the adult range, using average estimated energy requirements to yield 800 to 1,200 mg/day for ages 1 to 3 years, 1,000 to 1,500 mg/day for 4 to 8 years, 1,200 to 1,800 mg/day for 9 to 13 years, and 1,500 to 2,300 mg/day for 14 years and older.4 Discussions of differences in salt-sensitivity may add more complexity to this picture, which is beyond the scope of this discussion.4
In addition to sodium and potassium, micronutrient antioxidants are also necessary to help modulate mechanisms of oxidative stress and endothelial function. Endothelial cells play an important role in regulating vascular homeostasis. The main mediator of vasodilation is nitric oxide released from endothelial cells which, through various mechanisms, affects vascular smooth muscle cells and causes their relaxation. Reactive oxygen species significantly reduce nitric oxide production, and antioxidants may act through this and other pathways to improve endothelial function.1
However, direct supplementation of isolated nutrients without the presence of deficiency is unlikely to provide any positive support and may cause more harm.1 Targeted intervention studies with micronutrient supplementation and BP present great methodological challenges and are scarce. The current research recommends meeting antioxidant needs through dietary intake at physiological levels.1
Hydration and Energy Drinks
Even mild dehydration is associated with kidney dysfunction, which may lead to the development of HTN. Data shows that many children fall short of the recommended daily fluid intake while overconsuming sugar-sweetened beverages (SSBs) and energy drinks. It has been shown that high consumption of SSBs elevates systolic BP and increases the risk of HTN among children. One comprehensive meta-analysis found that high consumption of SSBs is significantly associated with an increased risk of both HTN and obesity in children and adolescents.1
The American Academy of Pediatrics advises youth aged 12 to 18 not to consume energy drinks and to limit their daily caffeine intake to 100 mg or less. In children and adolescents, excessive consumption of energy drinks may result in HTN, tachycardia headaches, palpitations, anxiety, and sleeplessness. In healthy youths, there is a link between acute energy drink use and significantly increased systolic and diastolic BP.1
A recent study reported that in healthy children and adolescents, consuming a single bodyweight-adjusted energy drink in the morning is associated with considerably increased 24-hour BP, both diastolic and systolic. Researchers say that energy drink consumption over many years may increase the risk of CVD in youths.5 A child’s main source of liquid in the diet should be water, and meeting hydration needs should be a primary intervention for pediatric HTN.
Making the Change
The American Heart Association points to research showing that taste preferences are shaped by what we eat early in life. Parents and caregivers should make gradual dietary changes to their kids’ diets with the help of a supportive provider team, including a dietitian. Family and community settings, including school environments, present daily opportunities to model and enforce positive behavior changes. RDs can contribute expert guidance in all these settings, offering practical and tasty food swaps lower in sugar and sodium and rich in antioxidants, potassium, and other essential micronutrients as well as helping to troubleshoot behavior change hurdles along the way.
— Heather Davis, MS, RDN, LDN, is editor of Today’s Dietitian.
References
1. Kozioł-Kozakowska A, Wójcik M, Herceg-Čavrak V, et al. Dietary strategies in the prevention and treatment of hypertension in children and adolescents: a narrative review. Nutrients. 2024;16(16):2786.
2. Bleich SN, Vercammen KA, Zatz LY, Frelier JM, Ebbeling CB, Peeters A. Interventions to prevent global childhood overweight and obesity: a systematic review. Lancet Diabetes Endocrinol. 2018;6(4):332-346.
3. Brown T, Moore TH, Hooper L, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2019;7(7):CD001871.
4. Gowrishankar M, Blair B, Rieder MJ. Dietary intake of sodium by children: why it matters. Paediatr Child Health. 2020;25(1):47-61.
5. Oberhoffer FS, Li P, Jakob A, Dalla-Pozza R, Haas NA, Mandilaras G. Energy drinks: effects on blood pressure and heart rate in children and teenagers. A randomized trial. Front Cardiovasc Med. 2022;9:862041.