Last year, Gurugram resident Smriti Malhotra, 20, had an accident. At the hospital, when her vital parameters were checked, her blood pressure was found to be high for her age. Her parents were shocked.“‘She is too young,’ we thought. Besides, our family has had no history of the disease. Her maternal grandmother does have high BP, but she’s in her mid-60s now,” says Seema Malhotra, Smriti’s mother, a homemaker. “My daughter always made healthy food choices. This was certainly disturbing.”
Smriti was subjected to a battery of tests, in an attempt to diagnose the cause of the high BP. “It was not easy to get through those months. More than us, it was difficult for Smriti. Her confidence was shaken,” says Seema. All her tests were normal, though. “No explanation could be found, and we were very confused. That is when I figured that my daughter had a lifestyle issue, one that went beyond her eating habits,” she says.
A student of banking and finance at a prestigious university in the United States, Smriti, says her mother, had been under stress for some time. “Good grades, adjusting to life in a new country, working through the nights, everything just added up. Our daughter was just too stressed out,” she says.
Smriti’s case, say experts, is among the rising incidence of high blood pressure in young people, particularly adolescents. Until now considered to be a disease of the adults, high blood pressure is now being diagnosed among adolescents, too.
An important distinction, though, must be made between primary and secondary hypertension. Several doctors that THE WEEK spoke to concurred that hypertension among children was common, and a majority of these patients were afflicted by kidney disorders. According to Dr Kanav Anand, paediatric nephrologist at Sir Ganga Ram Hospital, 65 per cent of children who have high blood pressure suffer from kidney disorders. This phenomenon is known as secondary hypertension.
Taking note of these disorders, the Indian Paediatric Nephrology Group advises that after three years of age, children should be screened annually for hypertension.
The more worrying trend, however, is the increasing number of school-going children suffering from essential or primary hypertension—high blood pressure where there is no underlying cause. In patients with primary hypertension, as studies note, the disease is strongly linked to obesity, a family history of hypertension, and several lifestyle factors.
According to a 2010 study published in the international journal, Pediatric Nephrology, primary hypertension emerges from a “complex interplay of genetic, environmental and behavioural factors”. The study says that owing to the “hereditary component” of hypertension, the disorder is “considered to have its origins in the young”, and hence, the need to take note of it early.
Similar studies suggest that globally, the disease is common among obese adolescents. In India, however, only a few studies on school-going adolescents have documented this trend. Based on the data from studies done in urban areas of Delhi, Bengaluru, Chennai, Surat and Shimla, and evidence from doctors, incidence of high blood pressure among teens ranges from less than 5 per cent to around 26 per cent.
In the study on adolescents in Bengaluru, published in International Journal of Contemporary Pediatrics last year, the authors note a higher prevalence of high blood pressure in southern India because of “increased genetic inheritance” as a result of higher “consanguineous marriages” (marriage among those related by blood), and lifestyle factors.
In another recent study conducted by a group of Delhi-based academics from the Department of Food and Nutrition, Lady Irwin College, Delhi University, a higher prevalence of hypertension was found among overweight or obese children, as compared to those with normal weight. Deepika Bahl, one of the lead researchers, says that for the study, she chose adolescents from four private schools in Delhi, and found that 13.6 per cent of overweight or obese children had high blood pressure. She also found that more boys had high BP than girls.
“The three main reasons for the disease were: skipping breakfast every day, a high rate of soft drink consumption, and screen time [television, computer, mobile phones] for more than two hours. Family history also plays a role,” says Bahl.
Many doctors agree that modern lifestyle has had a huge role to play in children suffering from this disorder. “Smoking is a major factor, as are sleep disorders. Obese children are certainly at high risk for getting this disease,” says Dr Sidharth Kumar Sethi, paediatric nephrologist at Medanta—The Medicity in Gurugram.
Others point to the increasing consumption of food with high sodium content such as packaged food and cold cuts, and a decrease in physical activity. “I see kids in front of television or mobile phones all the time. For instance, playing cricket today is not an activity kids enjoy outdoors. Rather, as a young teen told me, it is limited to sitting in front of the TV to watch the IPL,” says Sethi, who is member of Indian Society of Pediatric Nephrology.
High BP manifests itself in typical symptoms such as headache, pain in the neck, inability to focus, fatigue and pain in the eyes, says Dr Aparna Jaswal, additional director, electrophysiology, Fortis Escorts Heart Institute, Delhi.
However, the disease may actually show no symptoms, says Bahl, who terms high blood pressure as a “silent killer” among adolescents. Smriti’s mother, too, recalls how her daughter never had any headaches that caused concern.
Awareness about the prevalence of high BP in school-going teenagers is low. When Bahl started her doctoral thesis in 2014, she approached a renowned private school in South Delhi. The administration, she says, refused to allow their students to be part of the study to measure BP. “Even parents felt that there was no need to test the children for hypertension. It is only after they saw the results that they were convinced,” she says.
The hidden nature of the disease could have serious consequences, say doctors. Damage to organs such as the heart is a possibility, especially in cases of mild to severe hypertension. “One of the consequences of high BP is damage to the heart, or a condition called left ventricular hypertrophy. In this, the valves of the heart on the left side are thickened because the heart is under pressure to pump more blood. For every case of hypertension, we need to look for this condition, too,” says Sethi, who is part of a study on school-going adolescents to detect “hidden” hypertension.
The process of diagnosing high blood pressure in children differs from that of adults. The 24-hour ambulatory blood pressure monitoring device is used more commonly, because it monitors the blood pressure through the day and night. In patients with hypertension, the BP does not dip at night, doctors say. Unlike adults, in children, the cut off values for BP are not standard but are calculated based on their age, gender, height and weight.
Once diagnosed with high BP, children are mostly advised to change their lifestyle by reducing salt intake, increasing physical activity, and including more fruits and vegetables in the diet. Medication is used in very few cases, where damage to organs is diagnosed.
Bahl feels that more needs to be done to help children avoid the risk of high blood pressure—breakfast should include three or more food groups in kids, no soft drinks, and specific time to be earmarked for physical activity. “In schools, games period should not be substituted for academics. One hour of games daily is mandatory for children,” she says.
Parents in India need to take the issue seriously. “People think it is okay to skip medicines when it comes to children, but that can be harmful in the long term,” says Seema. For now, she has a sound prescription for her daughter: take regular medication, rest well and avoid stress.
Some names have been changed.
Young and vulnerable
Causes of hypertension in children
Kidney diseases are the most common cause of secondary hypertension. Disorders of the heart, blood vessels and hormones, and tumour or drugs could also cause high blood pressure.
In primary or essential hypertension, family history, obesity and lifestyle factors play a role.
* Stress management
* Reduce salt intake (sodium intake less than 3.5gm a day)
* Eat breakfast, including three food groups, regularly
* 60 minutes of daily physical activity, and reduced screen time
* Lose weight
* Quit smoking
* Limit alcohol consumption
* Avoid sugary drinks
Source: Dr Kanav Anand and Dr P.K. Pruthi, Sir Ganga Ram Hospital, New Delhi; Deepika Bahl, PhD scholar, Lady Irwin College, New Delhi