Brazilian Journal of Medical and Biological Research (2006) 39: 1637-1642 1637

Cardiovascular risk factors in schoolchildren

ISSN 0100-879X

Cardiovascular risk factors in a

population of Brazilian schoolchildren

A.N. Rodrigues1,2, 1Departamento de Ciências Fisiológicas, Centro de Ciências da Saúde,

M.R. Moyses1, N.S. Bissoli1,2, Universidade Federal do Espírito Santo, Vitória, ES, Brasil
2Faculdade Salesiana de Vitória, Vitória, ES, Brasil
J.G.P. Pires1 and G.R. Abreu1,2

Abstract

Correspondence Epidemiological and clinical evidence suggests that a judicious diet, Key words
G.R. Abreu regular physical activity and blood pressure (BP) monitoring must • Cardiovascular risk factors
Centro de Ciências da Saúde, UFES start in early childhood to minimize the impact of modifiable cardio- • Arterial hypertension
Av. Marechal Campos, 1468
vascular risk factors. This study was designed to evaluate BP and • Primary prevention
29042-755 Vitória, ES • Coronary artery disease
Brasil
metabolic parameters of schoolchildren from Vitória, Espírito Santo
• Obesity
Fax: +55-27-3335-7330 State, Brazil, and correlate them with cardiovascular risk factors. The
• Schoolchildren
E-mail: [email protected] study was conducted on 380 students aged 10-14 years (177 boys, 203
girls) enrolled in public schools. Baseline measurements included
body mass index, BP and heart rate. The students were submitted to
exercise spirometry on a treadmill. VO2max was obtained from exercise
Received January 17, 2006
testing to voluntary exhaustion. Fasting serum total cholesterol (TC),
Accepted August 23, 2006
LDL-C, HDL-C, triglycerides (TG), and glucose were measured. Nine
point nine percent of the boys and 11.7% of the girls were hyperten-
sive or had pre-hypertensive levels. There was no significant correla-
tion between VO2max and TC, LDL-C, or TG in prepubertal children,
but a slight negative correlation was detected in post-pubertal boys for
HDL-C and TG. In addition, children with hypertension (3.4%) or pre-
hypertensive levels (6.6%) also had comorbidity for overweight and
blood lipid abnormalities (14% for triglycerides, 44.7% for TC, 25.9%
for LDL-C, 52% for low HDL-C). The present study shows for the first
time high correlations between prehypertensive blood pressure levels
and the cardiovascular risk factors high TC, high LDL-C, low HDL-C
in schoolchildren. These are important for the formulation of public
health policies and strategies.

Introduction ment of hypertension and other cardiovascu-

lar diseases (1,2). There is evidence that
Although the idea that atherosclerosis serum cholesterol levels in infancy correlate
begins in infancy was proposed as early as in with mortality by coronary disease in the
1914, only in the last decade was it recog- adulthood (2). In addition, there is a well-
nized as a pediatric problem (1). Clinical and known association between hypertension and
epidemiological studies have suggested that lipid abnormalities, particularly high levels
periodic blood pressure (BP) and biochemi- of serum LDL-cholesterol (LDL-C) (2).
cal determinations in schoolchildren permit It is accepted that risk factors for cardio-
the early detection of risk factors and treat- vascular diseases, when detected in school-

Braz J Med Biol Res 39(12) 2006

1638 A.N. Rodrigues et al.

children, are predictive of coronary disease. between risk factors and arterial hyperten-
Thus, early detection of such risk factors can sion.
be crucial to establish prognosis and to pre-
vent target-organs damage in adulthood (3,4). Subjects, Material and Methods
Although the clinical manifestations of hy-
pertension and coronary disease occur in Schoolchildren aged 10-14 years (177
adulthood, the primary prevention of such boys and 203 girls) enrolled in all the public
conditions should start in childhood (3,4). schools of Vitória city, were randomly allo-
For practical and epidemiological rea- cated to this cross-sectional study. Data were
sons, childhood represents a good opportu- collected between March 2003 and March
nity for studies regarding the detection/pre- 2005. The study was approved by the Ethics
vention of modifiable cardiovascular risk Committee of Faculdade Salesiana de Vitória
factors, including sedentary lifestyle, hyper- and written parental consent was obtained in
caloric food intake and overweight/obesity. all cases, after the parents were informed of
If initiated during early childhood, appropri- the purpose of the investigation, procedures,
ate changes in lifestyle patterns should be benefits, and risks.
able to reduce the later incidence and sever- Data initially obtained by standard meth-
ity of cardiovascular diseases (4,5). Despite ods were age at the time of the study (years,
the existence of published studies dealing presented in decimal format), body weight
with the prevalence of cardiovascular risk (kg), and height (m). Body mass index (BMI)
factors and/or the correlation among athero- was then calculated from body weight and
sclerosis risk factors in Brazil (6-8), popula- height and expressed as kg/m2. The criteria
tion studies in schoolchildren in our region established in 1995 by the WHO (9), in 2000
are lacking. Therefore, the present study was by Cole et al. (10), and in 2005 by Daniels et
designed to evaluate the metabolic profile al. (11) were used to determine the condi-
(e.g., serum lipids, glucose, etc.) and the tions of thinness, overweight and obesity.
aerobic fitness of schoolchildren (including Sexual maturity was assessed by the occur-
adolescents) from a population in the Vitória rence of menarche in girls and by the pres-
area, Eastern Brazil, looking for correlations ence of axillary hair in boys (12,13).
Students were interviewed about their
Table 1. General characteristics of the schoolchildren enrolled in the study. Vitória, lifestyle and family history of cardiovascu-
ES, Brazil, 2005. lar diseases and assessed for cardiovascular
parameters and exercise capacity. Children
Parameter Boys Girls
were then submitted to standard ECG, from
Age (years) 12.6 ± 1.48 12.4 ± 1.41 which heart rate was determined. Resting
BMI (kg/m2) 18.2 ± 3.37 18.7 ± 3.37 arterial BP was measured using a mercury
VO2max (mL kg-1 min-1) 45.5 ± 8.41 37.9 ± 5.94*
Heart rate (bpm) 76 ± 9 81 ± 9 sphygmomanometer with appropriate arm
Systolic blood pressure (mmHg) 107 ± 11 108 ± 9 cuff length; the average of three determina-
Diastolic blood pressure (mmHg) 63 ± 7 64 ± 7 tions was used. Criteria for classification as
Fasting glucose (mg/dL) 82.7 ± 7.43 81.3 ± 6.93
Triglycerides (mg/dL) 70.4 ± 32 77.5 ± 29
normotensive, borderline or hypertensive
Total cholesterol (mg/dL) 150.9 ± 27 151.3 ± 29 took into account BP values for the 90th and
LDL-C (mg/dL) 91.4 ± 23 91.2 ± 27 95th percentiles. Thus, values below the 90th
HDL-C (mg/dL) 45.4 ± 10 44.6 ± 8
percentile were considered normotensive and
The study group was composed of 177 boys and 203 girls. BMI = body mass index; values above the 95th percentile were con-
VO2max = maximal oxygen consumption; LDL-C = LDL-cholesterol; HDL-C = HDL- sidered hypertensive (14-17). To determine
cholesterol. aerobic capacity based on maximal oxygen
*P < 0.05 compared to boys (Student t-test).
consumption (VO2max), the schoolchildren

Braz J Med Biol Res 39(12) 2006

Cardiovascular risk factors in schoolchildren 1639

were submitted to ergospirometry (CardiO2, account values above the 90th percentile.
MedGraphics Co., St. Paul, MN, USA) on a Borderline high BP was detected in 5.1% of
treadmill. VO2max was obtained from exer- the boys and 7.9% of the girls. Increased
cise testing to voluntary exhaustion (18). A serum cholesterol was found in about 20%
cardiac defibrillator and adequate resuscita- of the children, regardless of gender. In ad-
tion equipment were available at all times dition, almost 50% of the schoolchildren
during the procedures. had abnormally decreased HDL-C values.
Fasting serum glucose, triglycerides, to- The differences between boys and girls re-
tal cholesterol (TC), LDL-C, and HDL-C garding the risk factors under study were not
were determined using conventional labora- statistically significant (data summarized in
tory enzymatic and colorimetric techniques. Table 2).
The reference ranges applied were based on Correlation coefficients (r) between the
international (19) and Brazilian (20) stan- levels of each serum lipid parameter and
dards, as follows: serum glucose 70-110 mg/ blood pressure, both systolic and diastolic,
dL, triglycerides >100 mg/dL, TC >150 mg/ were also determined. In this analysis, the
dL, LDL-C >100 mg/dL, and HDL-C ≥45 students were classified as “before” or “af-
mg/dL. ter” sexual maturation. Only in the pre-pu-
Unless otherwise stated, data are pre- bertal girls subgroup was a significant posi-
sented as means ± SEM. The Student t-test tive correlation detected between serum li-
was used for comparison between two means pid parameters and blood pressure (r = 0.24,
and the chi-square test or odds-ratio deter- P = 0.039).
mination was used for multiple proportion Table 3 shows the r values for correlation
comparisons, as appropriate. When appro- between each serum lipid level and VO2max
priate, linear regression was performed or and BMI for boys and girls. Similar correla-
Pearson’s correlation coefficients were cal- tion coefficients were determined between
culated. In all cases, the level of significance systolic and diastolic arterial pressure and
was set at P < 0.05. the same two parameters, namely VO2max
and BMI. The schoolchildren were divided
Results
Table 2. Prevalence of cardiovascular risk factors
Among the 177 boys and 203 girls en- in a sample of schoolchildren from Vitória, ES,
rolled in this study, 38.4 and 45.8%, respec- Brazil.
tively (P < 0.05), were sexually mature. The
Risk factor Boys Girls
mean age of the schoolchildren was 12.6 and
12.4 years, for boys and girls, respectively, Overweight 9.6% 7.4%
with no significant difference between gen- Obesity 6.2% 4.9%
Borderline hypertension 5.1% 7.9%
ders. Table 1 shows these and the other gen- Hypertension 3.4% 3.4%
eral characteristics of the study sample. It can Borderline triglycerides 6.8% 11.8%
be seen that there was no statistically signifi- Increased triglycerides 3.4% 5.9%
Borderline total cholesterol 24.9% 24.6%
cant difference between boys and girls regard- Increased total cholesterol 19.2% 20.7%
ing the variables studied, except for VO2max, as Borderline LDL-C 18.1% 20.7%
expected from the literature (e.g., Ref. 18). Increased LDL-C 5.7% 7.4%
Decreased HDL-C 56.5% 47.8%
We classified 9.6% of the boys and 7.4%
of the girls as overweight, and 6.2 and 4.9% The differences between 177 boys and 203 girls
as obese, respectively (Table 2). Regarding for these factors were not statistically significant
resting BP values, hypertension was detected (confidence interval for odds ratios). LDL-C = LDL-
cholesterol; HDL-C = HDL-cholesterol.
in 3.4% of both boys and girls, taking into

Braz J Med Biol Res 39(12) 2006

1640 A.N. Rodrigues et al.

into two categories, concerning sexual matu- region’s public health policy. The overall
ration (Table 3). Among the boys, there occurrence of overweight or obesity was
were statistically significant inverse correla- about 13.9% for the schoolchildren, a level
tions between VO2max and TC and triglyceri- that, although slightly lower than those re-
des, but only in the post-pubertal students. In ported for the United States (21), Europe
addition, among the post-pubertal boys BMI (22) and some other regions of Brazil (6,23),
correlated positively with TC, LDL-C, and suggests that obesity among children is el-
systolic and diastolic BP. Among the girls, evated, and might become a public health
the only significant correlation between problem in the Vitória city area. In a study
VO2max and the measured parameters was by Guimarães and Guimarães (8) conducted
detected with serum triglycerides in the pre- in Salvador, BA, the prevalence of over-
pubertal subgroup; nevertheless, it was a weight/obesity among 6-12-year-old school-
very small correlation (r = 0.08, P > 0.05). In children was similar to that reported here.
addition, BMI positively correlated with sys- This is an important issue in view of the
tolic arterial pressure in both pre- (r = 0.24, association between obesity and heart dis-
P = 0.02) and post-pubertal (r = 0.47, P = eases and stroke (24).
0.005) girls. Serum glucose levels were Total serum cholesterol was high in about
within the normal range in both sexes, with 20% of the schoolchildren studied. This fig-
girls and boys exhibiting similar values (82 ure is slightly lower than those observed in
± 6 vs 78 ± 7 mg/dL). other Brazilian urban areas (25-27). As shown
in Table 3, a limited number of significant
Discussion correlations are demonstrable between some
biochemical markers and BMI among boys,
The present results characterize a par- but not among girls. These gender differ-
ticular epidemiological condition in a popu- ences have been reported by others (1,28)
lation of 10-14-year-old Brazilian school- and could be due to gonadal hormone influ-
children. Since such population studies are ence, although the molecular mechanisms
relatively scarce in Brazil, the present results involved are not understood.
can provide important information for the The significant correlation detected be-
tween BMI and systolic pressure among the
girls (Table 3) also deserves mention, since,
Table 3. Correlation (r ) of VO2max and body mass index with lipid and blood pressure to our knowledge, this has not been de-
values among the schoolchildren studied: influence of sexual maturation.
scribed before. It remains to be proved if the
VO2max BMI hemodynamic consequences of obesity are
involved in this association. It seems that
Boys Girls Boys Girls
gonadal influences do not account for this
Before After Before After Before After Before After effect, since correlation between obesity and
hypertension was observed in both sexes
Cholesterol -0.02 -0.33* -0.09 -0.04 -0.02 0.23 0.00 -0.12 (Table 3).
HDL-C 0.08 0.09 -0.07 0.02 0.02 -0.32* -0.16 -0.17
LDL-C -0.05 -0.29* -0.09 -0.03 -0.05 0.33* 0.02 -0.09
The present results showing hypertriglyc-
Triglycerides -0.00 -0.36* 0.07 -0.08 0.05 0.22 0.13 0.04 eridemia in about 4% and hypertension +
Systolic BP 0.09 -0.11 0.01 -0.09 0.09 0.44* 0.16 0.35* borderline BP in about 12% of the school-
Diastolic BP 0.00 -0.15 0.01 -0.08 0.00 0.22 0.04 0.12
children irrespective of gender, agree with
Values are correlation coefficients (r ). VO2max = maximal oxygen consumption; BMI = most of the data from the Brazilian and
body mass index; “Before” and “After” = before or after sexual maturation; LDL-C = international literature (21-28). However, our
LDL-cholesterol; HDL-C = HDL-cholesterol; BP = blood pressure.
data showing that about 1/5 of the students
*P < 0.05 (Fisher test).
have increased LDL-C represent higher val-

Braz J Med Biol Res 39(12) 2006

Cardiovascular risk factors in schoolchildren 1641

ues than those reported in other studies (21- weight + obesity (as suggested by the corre-
28), possibly reflecting local nutritional as- lation detected between BMI and BP), al-
pects, which also deserve further investiga- though other factors cannot be ruled out.
tion. The present data provide a general pic-
An interesting result was the correlation ture of our population of schoolchildren in
observed between maximal oxygen con- terms of cardiovascular risk factors and their
sumption and some serum lipids (Table 3), association with arterial pressure. It is ex-
for which we have no explanation. pected that such data may be useful for the
Our results regarding schoolchildren in implementation of preventive strategies dur-
Vitória also show that the prevalence of ing childhood, including the control of con-
borderline hypertension + hypertension is ditions such as overweight, borderline hy-
lower than the rates reported in other similar pertension and dyslipidemia, which could
Brazilian studies (29,30). This difference help early prevention of cardiovascular dis-
could be due to our lower levels of over- eases.

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