Differences in Blood Pressure Levels Among Children by Sociodemographic Status

Melissa Goulding, MS; Robert Goldberg, PhD; Stephenie C. Lemon, PhD


Prev Chronic Dis. 2021;18(9):e88 

In This Article

Abstract and Introduction


Introduction: The American Academy of Pediatrics (AAP) updated its blood pressure (BP) screening guidelines in 2017 to emphasize body weight as a risk factor. We provide contemporary, nationally representative estimates of prevalence of elevated and hypertensive BP among US children and examine sociodemographic prevalence differences, accounting for the influence of weight.

Methods: We used cross-sectional data from children aged 8 to 17 years (N = 5,971; weighted N = 36,612,323) collected from 2011 through 2018 in 4 biennial cycles of the National Health and Nutrition Examination Survey (NHANES). Children's BP was categorized as normal, elevated, or hypertensive. Sociodemographic characteristics included were sex, age, race/ethnicity, family income, and education. Log binomial regression, with and without adjustment for weight (dichotomized at the 85th body mass index percentile), determined prevalence estimates and differences for elevated and hypertensive BPs with 95% CIs.

Results: In NHANES data collected from 2011 through 2018, 7.2% (95% CI, 6.3%–8.3%) of US children had elevated BP, and 3.8% (95% CI, 3.3%–4.5%) had hypertensive BP according to 2017 AAP guidelines. Differences in prevalence of weight-adjusted elevated BP indicated higher prevalence among children aged 16 to 17 years compared with children aged 8 to 9 years (prevalence difference, +6.3%; 95% CI, 3.2%–9.4%), among males compared with females (+4.6%; 95% CI, 2.7%–6.4%), and among non-Latino Black children compared with non-Latino White children (+4.0%; 95% CI, 2.2%–5.8%). Crude hypertensive BP prevalence was highest among children aged 8 to 9 years, male children, and Mexican American children. The only difference remaining after weight adjustment was among children aged 8 to 9 years and 13 to 15 years.

Conclusion: Elevated BP was most prevalent among US children who were older, male, or non-Latino Black. Factors beyond inequalities in body weight may contribute to disparities in elevated BP.


Hypertension affected nearly 4% of US children from 2013 through 2016.[1] The high prevalence of childhood obesity has contributed to an increase in several chronic conditions among children, including hypertension.[2] Children who are overweight have higher systolic and diastolic blood pressure (BP)[3] than normal-weight children, and those with obesity have a threefold higher risk of hypertension compared with children of healthy weight.[4] Given the relationship between weight and BP, the American Academy of Pediatrics (AAP) changed its clinical practice guidelines in 2017 with new normative pediatric BP tables to assess children's BP percentiles and categories on the basis of healthy body weight, in contrast to their previous guidelines, which included children of all weight statuses.[5] Prevalence estimates based on AAP's earlier guidelines may have been biased by body weight and therefore warrant reinvestigation. Although AAP's guideline changes increased estimated prevalence of hypertension among US children (from 1.9% to 3.5%),[1] national estimates beyond 2016 are unavailable.[1,5,6]

Few studies have described sociodemographic factors associated with hypertension among US children. Although prevalence in those studies appears to be higher among males and among Black, Mexican American, and other Latino children,[1,5,7–9] many of those studies were based on past AAP guidelines[10] and few investigated the extent to which disparities in BP could be explained by differences in weight.[7,9] Furthermore, investigation of potential associations between hypertension and socioeconomic factors has been limited.[11,12]

The objective of our study was to provide nationally representative prevalence estimates of elevated and hypertensive BP among US children according to 2017 AAP guidelines. We also examined sociodemographic differences in prevalence and explored the role of weight status in relationship to differences in BP levels.