February 2019 Issue

CPE Monthly: Hypertension in Children and Adolescents
By Molly Chaffin, MS, RD
Today's Dietitian
Vol. 21, No. 2, P. 42

Suggested CDR Learning Codes: 4040, 5070, 5080, 5260
Suggested CDR Performance Indicators: 8.1.4, 8.1.5, 8.4.1, 9.6.1
CPE Level 2

Take this course and earn 2 CEUs on our Continuing Education Learning Library

Hypertension, or chronic elevated blood pressure, is considered one of the main factors contributing to heart disease, yet it's largely preventable through proper nutrition and lifestyle behaviors. The prevalence of hypertension worldwide is astonishingly high—approximately 40% of people older than 25 are diagnosed with high blood pressure.1 Hypertension can increase mortality risk exponentially for those suffering from other chronic diseases such as diabetes and kidney failure, and it's responsible for approximately one-half of deaths from CVD and stroke. The World Health Organization predicts that if actions aren't taken to reduce hypertension rates, deaths resulting directly or indirectly from hypertension will continue to increase worldwide.

An increase in prevalence of hypertension also has been observed in children and adolescents.2,3 Although hypertension in children rarely results in mortality during youth, its effects can cause damage to other organs that may elevate the risk of disease later in life; for example, 30% to 40% of hypertensive children also were found to have mild to severe left ventricular hypertrophy, or a thickened muscular wall of the heart's left chamber.2 In addition, elevated blood pressure during childhood is strongly associated with hypertension during adulthood.4 This association, often described as the tracking phenomenon, indicates a need for greater focus on hypertension in children.2

Because blood pressure is known to increase with age, it's difficult to specify a blood pressure level (in mm Hg) that defines hypertension in children. According to the European Society of Hypertension's guidelines, hypertension in children is defined as systolic and/or diastolic blood pressure levels consistently above the 95th percentile for age, sex, and height measured on at least three occasions.2 Children whose levels regularly fall between the 90th and 95th percentiles are considered to have high-normal blood pressure. Because these definitions are based on percentiles, prevalence rates of childhood hypertension should remain a steady 5% of the population. Obesity, however, is significantly associated with an increase in blood pressure, and with the rise in childhood obesity, the prevalence rate of childhood hypertension is climbing and can be expected to continue. A recent study of children aged 3–11 found that the risk of developing hypertension is doubled in obese children and quadrupled in severely obese children compared with that of normal-weight children.3 Due to this association, it's expected that hypertension rates in children have increased and will continue to rise along with childhood obesity rates. A review of the National Health and Nutrition Examination Survey (NHANES) from 1988–2008 found that the prevalence of hypertension rose 3.4% in boys and 4.4% in girls, while BMI rose 0.7 and 1 kg/m2, respectively.5

The growing prevalence of hypertension in children and the detrimental effects of hypertension carrying over into adulthood suggest a need for increased screening for elevated blood pressure in children, preventive action to decrease potential risk factors for developing hypertension during childhood, and more rigorous management of hypertension in children, especially those diagnosed with additional comorbidities such as diabetes, heart failure, and kidney disease.6

This continuing education course reviews current research regarding hypertension in children and defines the dietitian's role in screening, prevention, and management of the condition.

Etiology and Prevention
Detecting elevated blood pressure levels early in childhood is crucial for initiating preventive measures and averting chronic high blood pressure into adolescence and adulthood. The European Society of Hypertension indicates that office blood pressure measurements should begin at age 3; follow-up measurements should occur yearly for children with high-normal blood pressure (above the 90th percentile) and every two years for normotensive children.2

Elevated blood pressure levels have been linked to various factors in both children and adults. Information regarding family medical history, anthropometrics, activity levels, and dietary intake often is collected during nutrition assessments, and the results of such assessments may indicate an increased risk of developing hypertension; therefore, children whose assessments reveal the following risk factors may benefit from more frequent collection of blood pressure measurements.

Genetics and Familial Factors
Hypertension often can be attributed to genetics; studies show a 15% to 40% heritability.2 Blood pressure levels were elevated in children whose parents shared common risk factors but no diagnosed hypertension; for example, paternal BMI was positively associated with a child's blood pressure level at age 5, while maternal BMI was found to be positively associated with systolic blood pressure levels in children.7

Alongside these physical factors, blood pressure in children may be attributed to family behavioral factors. Average systolic and diastolic blood pressure levels were significantly higher in children of mideducated women (+1 mm Hg and 0.9 mm Hg) and low-educated women (+2.2 mm Hg and 1.7 mm Hg) compared with levels of children of high-educated women. Shorter breast-feeding duration, while found to be correlated with maternal education, also was associated with increased blood pressure levels in children.7 It appears that socioeconomic status also may play a role in a child's risk of developing hypertension, and further research is needed to determine which, if any, parental behaviors are more strongly associated with blood pressure levels. Recognizing these familial factors during an assessment may indicate a need for more regular blood pressure screening and monitoring in children.6

As previously mentioned, overweight and obesity is significantly associated with elevated blood pressure in children.3,5 BMI is the strongest determining factor for hypertension and prehypertension in children and therefore the main preventive factor for the development of hypertension.2 A 2016 study found that parents of overweight children tend to underestimate their children's weight status and neglect to link overweight or obesity in children to disease risk.8 Other research has found that pediatricians are less likely to refer overweight and obese children to weight management counseling than underweight children who require nutrition care to promote weight gain, and many doctors neglect to address obesity in children unless additional obesity-related diseases are present.9 Obesity-related outcomes such as hypertension and prehypertension in children may not be addressed at an early enough stage to begin preventive strategies.

Multiple retrospective studies have determined an association between certain dietary factors and elevated blood pressure levels in children. Higher intakes of sodium and added sugars and lower intakes of potassium have been most strongly associated with high blood pressure levels and should be considered in the prevention of hypertension in children.

Reduction of sodium in particular has been a primary focus for preventing elevated blood pressure levels in both children and adults. Sodium levels in the body are regulated through the kidneys and affect blood pressure levels by retaining or excreting water to maintain sodium and potassium homeostasis. As sodium levels increase, the kidneys retain water to maintain a balanced sodium concentration. Blood pressure then increases to accommodate increased water retention. Therefore, sodium and potassium intakes are thought to play a role in the development of hypertension.

Average sodium consumption in the United States exceeds the recommended upper intake levels in both children and adults. Campbell and colleagues found that 54% of US children 18 months or older exceed the recommended daily intake of sodium, with the majority of sodium consumption attributed to bread, cheese, cereal, soup, processed meats, and mixed dishes.10 Moving into adolescence, more than 90% of school-age children were found to consume greater than the recommended daily intake of sodium, with an average 3,279 mg/day, approximately 40% greater than the recommended upper intake of 2,300 mg/day.11 In school-age children, three-quarters of daily sodium intake was found to come from commercially packaged foods, with the highest sodium contribution from pizza and fast food.

These findings regarding elevated sodium intake in children have been linked in many studies not only to higher blood pressure levels but also to other cardiovascular risk factors.12-15 A 2006 meta-analysis shows that the majority of research on salt intake and blood pressure in children found a positive association between sodium intake and blood pressure levels; on average, a 42% reduction (approximately 1,100 mg) of daily sodium intake resulted in an average decrease in systolic and diastolic blood pressure levels of 1.2 and 1.3 mm Hg, respectively.12 According to NHANES data, children with an average sodium consumption of >3,450 mg/day were at a 36% greater risk of hypertension compared with children who consumed less than 2,300 mg/day.5 Similar results were discovered by Yang and colleagues, who observed blood pressure levels rising an average of 1 mm Hg for every 1,000 mg sodium consumed daily by adolescents aged 8–18.16 These associations were particularly important in overweight or obese adolescents, with every 1,000 mg rise in sodium intake per day increasing the risk of hypertension by 74% among overweight and obese children but only 6% in normal-weight children. In a separate study, sodium intake was found to be significantly associated with obesity independent of caloric consumption in adolescents aged 14–18; increases in sodium intake were positively associated with weight, BMI, waist circumference, and percent body fat despite adjusting for various confounders such as age, physical activity, and energy intake.17

Other studies, however, found no correlation between sodium intake and blood pressure in children. For example, Buendia and colleagues' 2015 longitudinal study of more than 2,000 adolescent girls found that participants who consumed more than 3,500 mg sodium per day were no more likely to have elevated systolic or diastolic blood pressure levels than were those consuming <2,500 mg/day (p=0.55 and p=0.66, respectively).18 Another study with a smaller sample found similar results, with no association between sodium intake and blood pressure levels in children aged 7–14. The authors hypothesized that this lack of association may be related to the age of the sample—younger children in whom vascular and renal function haven't yet been impaired.14 Changes in salt intake are more strongly associated with blood pressure in older adults, and similar results were discovered about salt's effect on blood pressure in pubertal but not prepubertal children.15 Additional research is necessary to determine a clear link between salt intake in children and higher blood pressure levels with age.

Due to potassium's relationship with sodium and water balance, potassium intake is thought to play a role in regulating blood pressure levels in children and adults. While Buendia and colleagues' cohort study found no association between sodium intake and blood pressure in adolescent girls, higher potassium intake was found to be significantly associated with lower blood pressure levels (p<0.001). The potassium-to-sodium ratio was inversely associated with blood pressure levels, but the results were slightly weaker when compared with potassium intake alone (p=0.04).18 As with sodium, however, the total evidence regarding potassium intake and blood pressure is mixed. According to long-term retrospective data gathered from NHANES, potassium intake had no significant association with blood pressure levels in children.5

Physical Activity
Regular physical activity provides benefits to the cardiovascular system, while more sedentary behavior may increase cardiovascular risk factors. Children with insufficient physical activity have been found to be three times more likely to develop elevated blood pressure levels.2 Sedentary behaviors, specifically watching television, were significantly associated with increased blood pressure levels, and higher parental television time was associated with children's screen time and sedentary time.8 Therefore, physical inactivity of both the parents and children may play a role in hypertension risk and prevention in children.

Primary management strategies in children must first consider the cause of hypertension and any underlying conditions. Treatment of primary hypertension must first address the above-mentioned risk factors, with a focus on lifestyle changes to manage these factors and reduce weight in overweight and obese patients, while management of secondary hypertension is contingent on the underlying cause or comorbidity. Often this management relies on pharmacological treatment to manage blood pressure secondary to management strategies of the underlying condition.2

Secondary Hypertension
Hypertension is a common result of conditions such as type 2 diabetes mellitus, kidney disease, and heart failure and can significantly increase the risk of organ decline and mortality, even in children.2 The lifestyle management strategies discussed on the following pages may be incorporated into management of secondary hypertension, with special considerations taken to first meet guidelines for the primary disease state such as potassium restriction in those with chronic kidney disease or physical activity restriction in children with heart failure. For children with these conditions, the primary lifestyle approach should focus on salt restriction.2 For children with metabolic syndrome or obesity-related type 2 diabetes, dietitians should first focus on weight management strategies, with secondary consideration directed toward the above recommendations of increasing fruit, vegetable, and dairy intake and reducing sodium, sugar-sweetened beverages, and processed food intake.2

Because hypertension management becomes secondary to treatment of the underlying condition, pharmacological treatment often is an effective method for early blood pressure management. Little research is available regarding the most effective medications for reducing mortality in hypertensive children.2 In adults, however, the following five classes of antihypertensive drugs are used: angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), beta blockers, calcium channel blockers, and diuretics.2 Individuals taking ACE inhibitors should avoid potassium and calcium supplements, while individuals on ARBs should avoid only potassium supplements. Patients prescribed beta blockers, calcium channel blockers, or diuretics should avoid natural licorice, while those taking ARBs should avoid grapefruit juice. Medications may be most effective with decreased sodium and calcium intake due to the nutrients' effects on blood pressure; however, supplementation of lost electrolytes, specifically potassium, may be necessary for individuals taking diuretics.19 The providing RDs should ensure that patients or caregivers are aware of these interactions when medications are involved in hypertension management.

Primary Hypertension
Overweight and obesity in children is the No. 1 lifestyle risk factor for developing hypertension, making weight management the primary goal for obesity-related hypertension interventions.2 As with blood pressure, weight is expected to increase with age and growth, and therefore obesity interventions in early childhood should be aimed at weight maintenance or moderate weight loss (approximately 1 to 2 lbs per week) in severe cases of obesity. Interventions involving both diet and exercise components are found to be most effective for improvements in both weight and blood pressure.2

The following dietary and physical activity recommendations have been shown to lower blood pressure in children and promote a healthy weight.

Dietary Strategies
Various dietary factors have been associated with blood pressure levels in children and adolescents. Possible contributors to elevated blood pressure levels include intake of sodium and added sugars. Increased intake of fruits, vegetables, and dairy products have been associated with decreased blood pressure levels in children. These five dietary components also align with the Dietary Approaches to Stop Hypertension (DASH) diet, which promotes meeting recommended daily intakes of eight food groups (grains, fruits, vegetables, low-fat dairy, meats, nuts/seeds/legumes, oils, and sweets) and limiting intakes of foods high in saturated fat (>3 g/serving), sodium (>480 mg/serving), and added sugars.20

A recent study using NHANES data from 2003–2012 found that most children met less than one-quarter of the DASH recommendations according to a DASH diet index scoring fat, protein, cholesterol, fiber, potassium, sodium, calcium, and magnesium intakes.21 DASH index scores also significantly decreased with age, with scores averaging 2 (out of 9 possible points) in elementary school participants, 1.87 in middle school participants, and 1.58 in high schoolers. While significant associations between DASH diet scores and blood pressure levels weren't found in elementary and middle school children, DASH scores were found to be strongly associated with systolic blood pressure levels in high school-age adolescents; in this study, every 1-point increase in DASH scores was associated with an average 0.46-mm Hg drop in systolic blood pressure.

Similar results were discovered in a study involving children with type 1 and type 2 diabetes.22 Using a DASH index score measuring recommended intakes of the eight DASH food groups, researchers found that each 10-point increase in diet scores (out of 80 maximum points) was associated with a 2.02-mm Hg decrease in systolic blood pressure levels in youth with type 2 diabetes. While both of these observational studies show significant beneficial effects on blood pressure with increasing DASH adherence, a randomized controlled trial using a DASH intervention didn't find such strong results.20 Although participants significantly increased DASH diet scores (specifically intakes of fruit, dairy, potassium, and magnesium) during the intervention, decreases in systolic blood pressure levels weren't significantly correlated (p=0.07). The DASH intervention was found to be more effective than that of the control group in decreasing blood pressure levels and BMI; however, adherence to the diet was modest, with only 21% of participants meeting a DASH dietary pattern following the intervention and only 10% maintaining the diet at follow-up.

Fruits and Vegetables
Beneficial changes in blood pressure were observed in studies involving some aspects of the DASH diet, such as increasing fruit and vegetable intake. The European Society of Hypertension recommends that children eat at least two servings of fruits and vegetables per day to decrease risk of hypertension2; however, other studies have found more significant decreases in blood pressure levels with higher intakes of fruits and vegetables. For example, in a longitudinal study conducted with young children, every 100 g increase in fruit or vegetable intake was associated with a 0.4 mm Hg decrease in blood pressure levels.15 In practice, these results translate to 0.5 mm Hg decreases in blood pressure for every additional daily serving of fruits or vegetables, such as one medium piece of fruit or 1/2 cup of vegetables.

Even greater reductions in blood pressure were found in an observational study in which increased fruit and vegetable intake was associated with decreases in fat, saturated fat, and sodium intakes—nutrients the DASH diet recommends limiting.23 Upon follow-up, this study found that participants who consumed four or more servings of fruits and vegetables per day as young children were found to have systolic blood pressure levels 4 mm Hg lower, on average, in adolescence compared with those who consumed fewer than four servings of fruits and vegetables.

While the increased intake of fruits and vegetables had a significant effect on blood pressure levels, even greater results were found in children who consumed higher intakes of fruits, vegetables, and dairy products. In participants consuming more than two servings of dairy per day, systolic blood pressure levels during adolescence were approximately 5 mm Hg lower than those of individuals with less intake. The most significant results, however, were found in those who consumed the highest intake of fruits, vegetables, and dairy, with average systolic blood pressure levels 7 mm Hg less than participants with low fruit, vegetable, and dairy intakes.23 A large cohort study also observed decreases in systolic and diastolic blood pressure levels (1.74 and 0.87 mm Hg, respectively) in children who consumed more than two servings of dairy per day compared with those with low intake.24 No changes in association were discovered in this study after adjusting for calcium, magnesium, and potassium intake, suggesting that dairy products may have antihypertensive properties outside of their individual nutrients. Guidelines recommend at least one serving of low-fat dairy per day in children to prevent or manage childhood hypertension; however, according to this research, encouraging intake of more than two servings per day may provide the most benefit in lowering blood pressure in children.2

Saturated Fat
While promoting dairy intake appears to be beneficial in the management of childhood hypertension, selecting low-fat dairy products may be important to achieve the same effects. DASH recommendations, as well as hypertension guidelines for children, suggest decreased saturated fat intake to reduce blood pressure levels.2,20 In a 2009 study, children who maintain lower intakes of saturated fat through childhood were more likely to have lower systolic and diastolic blood pressure levels (approximately 1 mm Hg on average) compared with children in the control group.25 Children consuming less saturated fat also were found to have significantly higher polyunsaturated fat and potassium intake, which could potentially play a role in the effects on blood pressure in participating children.

Added Sugars
Added sugar intake, specifically from sugar-sweetened beverages, has been linked to increased blood pressure levels in children. Nguyen and colleagues determined that adolescents who consumed the highest category of sugar-sweetened beverages (>36 oz per day) had average blood pressure levels approximately 2 mm Hg higher than those of participants who consumed no sugar-sweetened beverages.26 Another study found a similar association between added sugar intake and diastolic blood pressure but not systolic blood pressure levels in children aged 7–12.14 Added sugars or sugar-sweetened beverages also may be indirectly related to increases in blood pressure levels through the association between added sugars and obesity.2 Therefore, limiting added sugar intake is recommended for both the management of hypertension and obesity in children.

While current research has produced mixed evidence regarding sodium's effect on blood pressure, some high-quality studies have found significant links between sodium and blood pressure that should be taken into consideration in the management of childhood hypertension.2,12 Sodium recommendations should remain at or near the daily allowance of 2,300 mg, specifically for adolescents, who appear to consume the most sodium and have the most significant reductions in blood pressure levels following sodium restriction.11,15,16 Sodium restriction also may be an effective strategy for hypertension management in overweight or obese children, with research showing that excess salt intake increases the risk of hypertension in obese children by 74%, while only increasing risk 6% in normal-weight children.16 It's therefore recommended that moderate sodium restriction be encouraged, specifically in older adolescents and overweight or obese children.

Reducing sodium intake may be effectively achieved in children's diets by decreasing common sources of excess sodium. Processed meats were found to be a significant source of sodium in young children's diets, while breads or "grain mixtures" tended to be the most significant source across all age groups.10 Limiting these foods as well as cheese, soups, and mixed dishes including pizza, pasta, and tacos may be an effective means to reducing sodium in children's diets. An additional study found that educating parents, specifically those in low-income families, whose sodium intake tends to be higher than average, resulted in increased salt knowledge and positive behaviors including label reading, purchasing lower-sodium foods, and using less salt when cooking.13

Physical Activity
Due to the link between physical inactivity and elevated blood pressure levels in children, physical activity recommendations should be included in hypertension interventions. The European Society of Hypertension's guidelines recommend at least 60 minutes per day of moderate to vigorous exercise for children.2 Väistö and colleagues, however, found that only unstructured physical activity, for example, recess, was significantly associated with decreased systolic blood pressure levels.27 These authors hypothesized that unstructured activity may provide more stress relief than organized sports or activities do, and this stress relief may offer additional benefit to blood pressure levels. A review of research regarding physical activity and blood pressure in children, however, found that overall, increased physical activity in children attenuated rises in blood pressure.28 While this review acknowledged the role of exercise and weight management in children (and the role of obesity and blood pressure), the compiled research found that blood pressure levels in children who lost approximately 2 kg were further lowered in those participating in regular exercise compared with those in intervention groups with similar weight loss who focused on diet alone. Therefore, it appears that physical activity provides additional benefits in the management of hypertension alongside weight management. Encouraging physical activity and unstructured play appears important for children to prevent or manage hypertension and achieve a healthy weight status.

Putting It Into Practice
According to the most recent research, dietary modifications aligning with the DASH diet and increased physical activity appear to be the most effective approach for lifestyle management of hypertension in children; however, effective change in a child's diet is often difficult to achieve in practice. Family-based approaches for achieving heart-healthy recommendations have been found to be effective methods for positively influencing children's diets and lifestyles.8 Parents' physical activity levels also were associated with children's physical activity levels outside of the home, revealing the importance of parental modeling in the home environment. Encouraging these healthful habits in the home environment, promoting parent modeling of healthful behaviors, and discussing self-regulation of food intake in children may promote these positive health behaviors.

Research also suggests that starting these healthful behaviors at a young age and continuing throughout childhood is important.24 Maintaining a healthy weight throughout childhood is equally important in preventing hypertension in children, and addressing overweight and obesity early may help to avert these and related conditions in adolescence. Pediatricians and other medical team members shouldn't hesitate to address excess weight in children and should closely monitor overweight or obese children for hypertension, with blood pressure measurements taken yearly, or biyearly when a normal weight status is achieved.2 Dietitians should work closely with providers to assess the need for dietary or lifestyle interventions early for patients at risk of developing hypertension during childhood. RDs also may play a role in identifying multiple risk factors in children including weight, genetics, and behavioral factors during clinical assessments. Recommending frequent blood pressure readings and appropriate lifestyle and behavior changes may decrease the risk of hypertension and related problems in adulthood.

— Molly Chaffin, MS, RD, works for the dietetic internship and online master's program at the University of Southern Mississippi, while offering nutrition consulting and educational talks at a fitness club in Vail, Colorado.

Learning Objectives
After completing this continuing education course, nutrition professionals should be better able to:
1. Discuss the increase in childhood hypertension and the condition's long-term damaging effects on the cardiovascular system.
2. Identify three factors that may indicate a child's risk of developing prehypertension or hypertension.
3. Compare three dietary modifications associated with decreased blood pressure rates in children.
4. Prepare a family-based management plan for childhood hypertension based on an individual's contributing factors, current diet and lifestyle behaviors, and home environment.

CPE Monthly Examination

1. According to the European Society of Hypertension's guidelines, which blood pressure level defines hypertension in children?
a. Consistently above 140/90 mm Hg
b. Consistently above 120/80 mm Hg
c. Consistently below the 85th percentile for age
d. Consistently above the 95th percentile for age

2. Which of the following risk factors is most strongly associated with developing hypertension in childhood?
a. Obesity
b. Sodium intake
c. Parental physical activity
d. Underweight

3. Limiting which of the following foods may have the strongest effect on sodium intake reduction in school-age children?
a. Milk
b. Table salt
c. Commercially packaged foods
d. Sugar-sweetened beverages

4. Patients taking angiotensin II receptor blockers should specifically avoid which of the following?
a. Protein supplements
b. Natural licorice
c. Grapefruit juice
d. Sodium

5. The Dietary Approaches to Stop Hypertension (DASH) diet recommends limiting foods containing more than what amount of sodium per serving?
a. 250 mg
b. 480 mg
c. 600 mg
d. 720 mg

6. Consuming at least how many servings of fruits and vegetables per day along with at least how many servings of low-fat dairy were found to have favorable results regarding blood pressure in children?
a. 2, 2
b. 2, 4
c. 4, 2
d. 4, 4

7. The European Society of Hypertension's guidelines recommend at least how many minutes per day of physical activity?
a. 90
b. 60
c. 30
d. 20

8. Sodium reduction as a blood pressure management strategy may be most effective in which population?
a. Prepubertal children
b. Physically active children
c. Underweight teens
d. Moderate to severely obese children

9. Which of the following is an effective intervention strategy for managing or preventing childhood hypertension in the home environment?
a. Parent modeling of physical activity
b. Restriction of salty snacks
c. Limiting screen time to two hours per day
d. Daily fruit juice consumption

10. Dietitians and pediatricians should work together to ensure which of the following?
a. Blood pressure levels are recorded every three years for overweight/obese children.
b. Healthful behaviors are initiated in older adolescence when dietary changes produce the most significant outcomes.
c. Early and effective lifestyle modifications are encouraged for children at risk of developing childhood hypertension.
d. Antihypertensive medications are prescribed upon the first measurement of elevated blood pressure levels.

1. World Health Organization. A global brief on hypertension: silent killer, global public health crisis. http://www.who.int/cardiovascular_diseases/publications/global_brief_hypertension. Published April 2013. Accessed June 5, 2017.

2. Lurbe E, Agabiti-Rosei E, Cruickshank JK, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hyptertens. 2016;34(10):1887-1920.

3. Parker ED, Sinaiko AR, Kharbanda EO, et al. Change in weight status and development of hypertension. Pediatrics. 2016;137(3):e20151662.

4. Tirosh A, Afek A, Rudich A, et al. Progression of normotensive adolescents to hypertensive adults: a study of 26,980 teenagers. Hypertension. 2010;56(2):203-209.

5. Rosner B, Cook NR, Daniels S, Falkner B. Childhood blood pressure trends and risk factors for high blood pressure: the NHANES experience 1988-2008. Hypertension. 2013;62(2):247-254.

6. Lawlor DA, Najman JM, Sterne J, Williams GM, Ebrahim S, Davey Smith G. Associations of parental, birth, and early life characteristics with systolic blood pressure at 5 years of age: findings from the Mater-University study of pregnancy and its outcomes. Circulation. 2004;110(16):2417-2423.

7. van den Berg G, Van Eijsden M, Galindo-Garre F, Vrijkotte TG, Gemke RJ. Explaining socioeconomic inequalities in childhood blood pressure and prehypertension: The ABCD study. Hypertension. 2013;61(1):35-41.

8. Vedanthan R, Bansilal S, Soto AV, et al. Family-based approaches to cardiovascular health promotion. J Am Coll Cardiol. 2016;67(14):1725-1737.

9. Mikhailovich K, Morrison P. Discussing childhood overweight and obesity with parents: a health communication dilemma. J Child Health Care. 2007;11(4):311-322.

10. Campbell KJ, Hendrie G, Nowson C, et al. Sources and correlates of sodium consumption in the first 2 years of life. J Acad Nutr Diet. 2014;114(10):1525-1532.

11. Cogswell ME, Yuan K, Gunn JP, et al. Vital signs: sodium intake among U.S. school-aged children — 2009-2010. MMWR Morb Mortal Wkly Rep. 2014;63(36):789-797.

12. He FJ, MacGregor GA. Importance of salt in determining blood pressure in children: meta-analysis of controlled trials. Hypertension. 2006;48(5):861-869.

13. Au LE, Whaley SE, Gurzo K, Meza M, Rosen NJ, Ritchie LD. Evaluation of online and in-person nutrition education related to salt knowledge and behaviors among Special Supplemental Nutrition Program for Women, Infants, and Children participants. J Acad Nutr Diet. 2017;117(9):1384-1395.

14. Kell KP, Cardel MI, Bohan Brown MM, Fernández JR. Added sugars in the diet are positively associated with diastolic blood pressure and triglycerides in children. Am J Clin Nutr. 2014;100(1):46-52.

15. Shi L, Krupp D, Remer T. Salt, fruit and vegetable consumption and blood pressure development: a longitudinal investigation in healthy children. Brit J Nutr. 2014;111(4):662-671.

16. Yang Q, Zhang Z, Kuklina EV, et al. Sodium intake and blood pressure among US children and adolescents. Pediatrics. 2012;130(4):611-619.

17. Zhu H, Pollock NK, Kotak I, et al. Dietary sodium, adiposity, and inflammation in healthy adolescents. Pediatrics. 2014;133(3):e635-642.

18. Buendia JR, Bradlee ML, Daniels SR, Singer MR, Moore LL. Longitudinal effects of dietary sodium and potassium on blood pressure in adolescent girls. JAMA Pediatr. 2015;169(6):560-568.

19. Pronsky ZM. Food Medication Interactions. 18th ed. Birchrunville, PA: Food Medication Interactions; 2015.

20. Couch SC, Saelens BE, Levin L, Dart K, Falciglia G, Daneils SR. The efficacy of a clinic-based behavioral nutrition intervention emphasizing a DASH-type diet for adolescents with elevated blood pressure. J Pediatr. 2008;152(4):494-501.

21. Cohen JF, Lehnerd ME, Houser RF, Rimm EB. Dietary Approaches to Stop Hypertension diet, weight status, and blood pressure among children and adolescents: National Health and Nutrition Examination Surveys 2003-2012. J Acad Nutr Diet. 2017;117(9):1437-1444.e2.

22. Barnes TL, Crandell JL, Bell RA, Mayer-Davis EJ, Dabelea D, Liese AD. Change in DASH diet score and cardiovascular risk factors in youth with type 1 and type 2 diabetes mellitus: the SEARCH for Diabetes in Youth Study. Nutr Diabetes. 2013;3:e91.

23. Moore LL, Singer MR, Bradlee ML, et al. Intake of fruits, vegetables, and dairy products in early childhood and subsequent blood pressure change. Epidemiology. 2005;16(1):4-11.

24. Yuan, WL, Kakinami L, Gray-Donald K, Czernichow S, Lambert M, Paradis G. Influence of dairy product consumption on children's blood pressure: results from the QUALITY cohort. J Acad Nutr Diet. 2013;113(7):936-941.

25. Niinikoski H, Jula A, Viikari J, et al. Blood pressure is lower in children and adolescents with a low-saturated-fat diet since infancy: the special turku coronary risk factor intervention project. Hypertension. 2009;53(6):918-924.

26. Nguyen S, Choi HK, Lustig RH, Hsu CY. Sugar-sweetened beverages, serum uric acid, and blood pressure in adolescents. J Pediatr. 2009;154(6):807-813.

27. Väistö J, Eloranta AM, Viitasalo A, et al. Physical activity and sedentary behaviour in relation to cardiometabolic risk in children: cross-sectional findings from the Physical Activity and Nutrition in Children (PANIC) Study. Int J Behav Nutr Phys Act. 2014;11:55.

28. Torrance B, McGuire KA, Lewanczuk R, McGavock J. Overweight, physical activity and high blood pressure in children: a review of the literature. Vasc Health Risk Manag. 2007;3(1):139-149.