Elevated blood pressure in youth in pediatric weight management programs in the Pediatric Obesity Weight Evaluation Registry (POWER)

Abstract Blood pressure (BP) assessment and management are important aspects of care for youth with obesity. This study evaluates data of youth with obesity seeking care at 35 pediatric weight management (PWM) programs enrolled in the Pediatric Obesity Weight Evaluation Registry (POWER). Data obtained at a first clinical visit for youth aged 3–17 years were evaluated to: (1) assess prevalence of BP above the normal range (high BP); and (2) identify characteristics associated with having high BP status. Weight status was evaluated using percentage of the 95th percentile for body mass index (%BMIp95); %BMIp95 was used to group youth by obesity class (class 1, 100% to < 120% %BMIp95; class 2, 120% to < 140% %BMIp95; class 3, ≥140% %BMIp95; class 2 and class 3 are considered severe obesity). Logistic regression evaluated associations with high BP. Data of 7943 patients were analyzed. Patients were: mean 11.7 (SD 3.3) years; 54% female; 19% Black non‐Hispanic, 32% Hispanic, 39% White non‐Hispanic; mean %BMIp95 137% (SD 25). Overall, 48.9% had high BP at the baseline visit, including 60.0% of youth with class 3 obesity, 45.9% with class 2 obesity, and 37.7% with class 1 obesity. Having high BP was positively associated with severe obesity, older age (15–17 years), and being male. Nearly half of treatment‐seeking youth with obesity presented for PWM care with high BP making assessment and management of BP a key area of focus for PWM programs.


INTRODUCTION
Child/adolescent obesity strongly tracks into adulthood 1,2 and conveys an increased risk for morbidity and mortality of cardiovascular disease in adulthood, with the strength of the relationship to risk for cardiovascular disease increasing as the child ages. 3,4 Obesity is an established risk factor for hypertension in youth and risk increases with severity of obesity. 5 A systematic review of 19 studies reported that youth with elevated blood pressure (BP) were more likely to have increased risk for markers of cardiovascular disease (such as high pulse wave velocity, high carotid intima-media thickness, left ventricular hypertrophy) in adulthood. 6 Thus, recognition of elevated BP by standardized BP measurement, and interpretation and early management are important aspects of optimal clinical care for youth with obesity.
Using current guideline interpretations for BP, 7 national samples report 27.5% of youth ages 12-19 years with obesity had BP above a normal range (ie, elevated, stage 1, or stage 2 classification; henceforth, high BP); and 30.6% of youth with severe obesity (defined as body mass index [BMI]-for-age ≥120% of the 95 th percentile) had high BP. 8 A recent report evaluated BP among national samples of youth ages 8-12 years and 13-17 years, reporting 2-3 times higher risk for high BP among youth with obesity as compared to youth of normal weight, but youth with severe obesity were not separately evaluated. 9 Because treatment of high BP in childhood could potentially reduce long-term cardiovascular risks, it is of particular importance to understand prevalence and risks for high BP among youth with obesity in the clinical setting to plan for their evaluation and management needs. This study evaluates data obtained in the Pediatric Obesity Weight Evaluation Registry (POWER). POWER is a consortium of multicomponent pediatric weight management (PWM) programs across the United States which prospectively enrolls patients seeking obesity management care and tracks parameters of care in an aggregate database. 10 Three-quarters of youth in POWER present with severe obesity. 11 This study aims to evaluate data from youth enrolled in POWER to: (1) assess prevalence of high BP in the clinical setting among care-seeking youth with obesity; and (2) identify characteristics associated with high BP status at a baseline visit.

METHODS
POWER was established in 2014 with the aim to better understand the complex nature of PWM and to collectively evaluate and improve medical care strategies for children and adolescents with obesity and improve health outcomes. 10  references. 13 BP interpretations were done using references in the 2017 guideline (SAS macro). 7 Obesity class groups were defined as follows: class 1, 100% to < 120% %BMIp95; class 2, 120% to < 140% %BMIp95; class 3, ≥140% %BMIp95; classes 2 and 3 were considered severe obesity. 14

Analyses
The frequency and percentage of patients overall, and for normal BP

RESULTS
Data on 7943 patients were analyzed; 54% were females. Patients were most often either Hispanic (32%) or White non-Hispanic (NH) (39%) and 59% had public health insurance (

DISCUSSION
Hypertension is a serious comorbidity associated with obesity across all ages, including children. 15 17 and in national surveys approximately one-third of patients had severe obesity. 5,8,18 In this report and prior POWER reports severe obesity status was reported for threequarters of the patients 11,18 ; among youth with most severe (class 3) obesity ∼60% had high BP. Youth with hypertension and obesity are often referred for PWM services due to the need for a multidisciplinary team approach available in these centers, 19,20 and that may also have been a contributing factor to the high rates of high BP observed in this sample.

Many of the characteristics significantly associated with high BP
in the initial visit for treatment-seeking youth with obesity were as expected. Youth with severe obesity status were at increased risk for high BP. Reinehr and coworkers found that obesity severity is an important risk for high BP. 17

Strengths and limitations
These data present information on nearly 8000 youth presenting for PWM care with the majority having severe obesity. Such information can foster the development of multidisciplinary strategies to address obesity and hypertension and help PWM programs to realize the high frequency at which they will need to optimally measure BP and treat elevated BP with appropriate lifestyle changes and pharmacotherapy. 31 While a limitation within POWER is the lack of information about BP measurement validation, these data were obtained during clinical care and highlight the diversity of the frequency of high BP between PWM programs. Individual PWM programs may wish to examine the frequency of high BP for their program in comparison to these data and, as necessary, review adherence to protocols for BP measurement.
Some patients may have already had a diagnosis of hypertension and were receiving antihypertensive medications for treatment at the time of their initial PWM visit. Diagnoses and medications were not uniformly collected and thus were not analyzed. Clearly, given this high frequency of high BP in this study, many PWM patients may need additional support to address hypertension and PWM clinicians will need to monitor if youth are taking antihypertensive medications as prescribed. Despite limitations, these data identify the high frequency of and important considerations for risk of high BP among treatment-seeking youth with obesity which can prompt PWM programs to develop strategies to address high BP in the youth they serve.

CONCLUSIONS
Nearly half of youth seeking PWM obesity care had BP values classified as high. Males, older teens, and youth with severe obesity were at highest risk for high BP. There were substantial differences in prevalence of high BP between POWER sites. Standardized, protocol-driven assessments and management of high BP should be key areas of focus for PWM programs.

AUTHOR CONTRIBUTIONS
All authors participated in study conception and design. Eileen King