European Journal of Cardiovascular Medicine

Obesity and Hypertension are emerging as major health problem among adolescent boys and girls, particularly in urban areas of India. Increasing physical inactivity and consumption of junk food contributes to excessive weight gain and obesity among adolescent boys and girls. The prevalence of Obesity among adolescents in India varies between 3.6% to 11.7%.¹ Various cross-sectional studies conducted in different parts of India have shown combined prevalence of obesity and overweight in the range of 6 to 25%.^5,6,7,8 There exists an association between obesity and hypertension.⁹ Overweight and obesity are mainly due to “caloric imbalance” and are affected by multiple factors including genetic, behavioural, environmental, and endocrinal factors. ^10,11,12 There is a high risk of development hyperlipidaemia, abnormal glucose tolerance, hypertension, coronary artery disease, obstructive sleep apnoea, infertility, orthopaedic problems etc. among Obese children and adolescents.^13,14

Several studies have reported the prevalence of Hypertension among Indian adolescents in the range between 0.46% to 15%.^{2, 15, 16} There is plenty of evidence to suggest that hypertension begins in childhood and adolescence. ^{17, 18, 19} The asymptomatic nature of hypertension in early phases of its onset during adolescence increases the chances of developing complications during adulthood. ²⁰ There is strong evidence that raised BMI during adolescence is associated with raised risk of developing hypertension and/or CVD as an adult ²¹ and there is a 12% increase in risk of developing CVD for each unit increase in BMI among adolescents. ²² With increasing prevalence, hypertension is becoming a rising health problem in children and adolescents. ^{23, 24}.

Childhood Blood pressure (BP) is a strong indicator of adult blood pressure, so, early intervention is important. ²⁵ There is paucity of data on prevalence and determinants of Obesity and HTN among adolescents residing in urban slums of Cuttack. Early detection of Hypertension and obesity during childhood and adolescence is important to identify those who are at increased risk of primary hypertension as adults, and who might benefit from earlier intervention and follow-up. ²⁶ With this background, the present study was conducted with an aim to estimate the prevalence of Obesity and Hypertension among adolescents of an urban slum of field practice area of SCB MCH, Cuttack. The objectives of our study were to study the socio-demographic profile of study participants, to study the correlates of Obesity and Hypertension and suggest remedial measures.

Study setting, design and study population: A community based cross-sectional study was conducted in the urban field practice area of SCB medical college and hospital, Cuttack, Odisha over a period of three months (from November 2023 to January 2024). A total of 152 adolescents (aged 10-19 years) were selected from households of 4 different wards (ward number- 35, 38, 39, and 40) of an urban slum in the field practice area of SCB MCH, Jobra, Cuttack. The study place was chosen because of its proximity to SCB MCH.

Inclusion criteria: Adolescent boys and girls (aged 10-19 years) residing in the study area for one year or more, willing to participate and provide written informed assent after explaining the study objectives were included in the study. Informed consent was also taken from the parents or guardians of adolescents before conducting the survey and prior to anthropometric and BP measurements.

Exclusion criteria: Adolescent boys and girls (aged 10-19 years) diagnosed with Hypertension, kidney ailments, mental illness, terminal illness, bed ridden, residing in study area for less than one year and those remaining absent on three consecutive visits were excluded from the study.

Sample size: A sample size of 152 was calculated using the Cochran formula, n= z²pq/d², taking prevalence of Hypertension among adolescents (p) as 10% from a previous study ²⁰, q as 90%, with standard normal deviate(z) of 1.96 at 95% confidence interval, an absolute precision of 5%, alpha error of 5% and assuming 10% non-response rate. A list of households from 4 different wards with adolescents (aged 10-19 years) was obtained from the family survey register of UHTC, Jobra. Households were selected by computer based random number generator using simple random sampling technique. One adolescent (aged 10-19 years) was selected from each household. In a household with two or more subjects, only one of them was selected randomly using lottery method.

Data collection Tools: A pre-designed, pre-tested, semi-structured schedule was prepared and validated by experts of Department of community medicine of SCB MCH. Data on socio-demographic profile, anthropometric measurements (weight, height, Blood Pressure, Body mass index), dietary habits and lifestyle of adolescents was collected by face-to-face interview using software application epicollect5. A digital weighing scale (Dr Trust) was used to measure the weight of the study participants. Height of the subjects was measured using a non-stretchable, flexible measuring tape. A standard Oscillo metric sphygmomanometer (Omron) was used to record the BP of the study participants, which was regularly standardized and checked to minimize errors.

Anthropometric measurements: Weight of the study participants was determined using a digital weighing scale (Dr Trust) without footwear and with light clothes. Recording of weight was made to the nearest 0.1kg. A non-stretchable, flexible measuring tape was used to measure height of the subjects to the nearest o.1cm. Participants were asked to stand in erect position against the wall with no footwear, feet kept together, buttocks and occiput touching the wall. A cardboard of minimal thickness was placed above the head and a marking was drawn on the wall using a pencil. Body mass index (BMI) of the study participants was calculated using the standard formula of a person's body weight (in kilograms) divided by the square of their height (in meters) and was categorised based on sex-specific BMI-for-age percentiles (or BMI percentiles) as per CDC 2000 Child and Teen BMI Calculator. ²⁷ Adolescents having BMI range of Less than the 5^th percentile, 5^th percentile to less than the 85^th percentile, 95^th percentile or greater, and 120% of the 95^th percentile or greater, or 35 kg/m² or greater were considered to have underweight, Healthy Weight, Overweight, obesity and severe obesity respectively. ²⁷

Blood Pressure (BP) measurement: Blood Pressure for each subject was recorded twice using a standard Oscillo metric sphygmomanometer (Omron) at an interval of 15 to 20 minutes. The average of two readings was calculated and considered as the final reading for analysis. Adolescents (aged 10-19 years) with SBP and DBP levels lower than 90^th percentile were considered normotensive, and subjects with BP level of 120/80 mm Hg or above, or average systolic blood pressure (SBP) or diastolic blood pressure (DBP) levels greater than equal to 90^th percentile, but less than the 95^th percentile, were classified as pre-hypertensive. Study participants were classified as hypertensive if their SBP or DBP or both were equal to or more than the 95^th percentile for age, sex, and height. ²⁸ The MSD manual calculator professional version software application was used to calculate the BP percentiles of subjects. ²⁹

DATA ANALYSIS

Data was analysed using the statistical package for social sciences (SPSS) software version 17.0. Categorical variables were expressed as percentages and continuous quantitative variables were expressed as mean and standard deviation. Pearson’s correlation test was applied to estimate linear relationship between continuous quantitative variables. Two tailed Chi-square test and Fischer’s exact test (*) was applied to compare proportions and find out association between dependent and independent variables. A p value of less than 0.05 was considered statistically significant.

The present study comprised a total of 152 adolescent boys and girls (aged 10-19 years) selected randomly from an urban slum of Cuttack. Amongst the 152 study participants, majority were males 90 (59.2%) as compared to females 62 (40.8%). The mean age of the study participants, males and females were 14.36±2.56 years, 13.91±2.55 years and 15±2.46 years respectively. Mean Body mass index (BMI) of the study participants was 22.58±3.26 kg/m². Mean Systolic Blood Pressure (SBP in mm Hg) was higher among males (113.53±9.34) as compared to females (112.26±8.70); however, mean Diastolic Blood Pressure (DBP in mm Hg) was slightly higher in females (70.10±5.65) as compared to males (69.69±6.93) in our study.

Table I: Anthropometric and Blood pressure profile of the study participants

The prevalence of obesity, overweight, healthy weight, and underweight among the study participants (as per BMI in percentile) were 10.5%, 31.6%, 55.3% and 2.6% respectively. Among males, 14 (15.5%) were obese, 24 (26.7%) were overweight and 52 (57.8%) had healthy weight and none (0.0%) were underweight. The present study revealed 02(3.2%), 24(38.7%), 32 (51.6%) and 04 (6.5%) female participants were Obese, Overweight, Normal (healthy weight) and underweight respectively. A significant association was found between BMI and gender, SES of the study participants in the current study (p<0.05).

Table II: Association between Gender and BMI among study participants

In our study, majority 88 (57.9%) of the participants reported playing sports or outdoor games sometimes in a week, 32 (21.1%) played outdoor games daily and remaining 32 (21.1%) subjects never played any outdoor games or sports. Among the participants, 20(13.1%) reported smoking either daily or sometimes in a week, 36 (23.7%) chewed smokeless tobacco either daily or sometimes in a week, 20(13.1%) revealed consuming alcohol occasionally. Majority 116(76.3%) of the participants reported with consumption of carbonated drinks occasionally, and 60 (39.5%) subjects consumed extra salt with diet.

Majority of the study participants, 133 (87.5%) were found to have normal blood pressure, while 08 (5.3%) and 11(7.2%) were Pre-Hypertensive and Hypertensive respectively. The prevalence of HTN was higher among females 7(11.3%) as compared to males 4(4.4%). However, there was no significant association between Hypertension and gender of the study participants. In current study, the prevalence of Hypertension was higher among obese participants (25%) as compared to overweight (12.5%), healthy weight (1.2%) and underweight participants (0.0%). Among the study participants, 09(5.92%) and 04(2.63%) had isolated systolic HTN and diastolic HTN respectively. A significant association between BMI and HTN (p<0.05) was found in our study. In the present study, association of HTN with duration of sleep (in hours), consumption of carbonated drinks, consumption of junk/fast/processed foods, academic stress, use of gadgets (in hours) was also found to be statistically significant (p<0.05). The current study revealed no significant association of HTN with gender, Socio-economic status (SES), Family history of HTN, extra salt with diet, smoking, alcohol consumption, use of smokeless tobacco, concern about self-appearance, outdoor games/sports. (p>0.05).

Table III: Association between HTN and BMI among study participants

Table IV: Association between HTN and independent variables

In our study, SBP (in percentile) (r=0.4), and DBP (in percentile) (r=0.5) showed a significant positive correlation with weight (kg) of the study participants (p <0.001). Age (in years) was also positively correlated with Systolic BP in mm Hg (r=0.29) and Diastolic BP in mm Hg (r= 0.39) with a p value of < 0.001. SBP (r=0.45) and DBP (r=0.42) also showed a significant positive correlation with BMI (kg/m²) (p<0.001). Significant correlation was also found between DBP (in percentile) and height (cm) of the study participants (r=0.24, p<0.05).

Figure 5: Correlation between weight and DBP (in percentile) among study participants

Obesity and Hypertension are rising health problems among adolescents with various prevalence rates in different parts of India. In the current study, majority of the study participants were males 90 (59.2%) as compared to females 62 (40.8%). This result was in accordance with the study findings by Suba Rajnikant B S et al. ³⁰ which included 255 (51.0%) males and 45(49%) females; S Banerjee et al. ³¹ which revealed 401(51.8%) boys and 373(48.2%) girls as study participants and Patil AD et al.³² which enrolled 774(52.1%) males and 712 (47.9%) females. However, in contrast to our result, study by Karimulla et al.³³ revealed that the total number of female participants 1027 (52.3%) outnumbered males 938 (47.7%). Also, study by Kumar P et al.³⁴ included higher number of females 1745 (59.9%) compared to males1168 (40.1%).

The mean age (14.36±2.56 years) and weight (50.11±10.0 kg) of the study participants in the current study were in accordance with the mean age (14.31± 0.961 years) and mean weight (49.10± 11.18 kg) of the school adolescents enrolled in a study by Anand et al.³⁵ However, mean age of participants was 11.81±1.72 years in a study by Patil AD et al.³² The mean height of 149.95±9.74 cm among the participants in the present study was consistent with the study finding by Karimulla et al. ³³, where the average height of their study participants was 147.02±11.15 cm; However, the mean weight of the present study subjects (50.11±10.0 kg) was inconsistent with the mean weight of the study population of Karimulla et al ³³ (37.96± 9.10)  Also, the mean height, BMI, SBP and DBP of our study participants differed slightly from the mean height, BMI, SBP and DBP of the study subjects by Anand et al³⁵.

The prevalence of Obesity among adolescents in the current study was 10.5%. This was consistent with the study finding by Mohan B et al. ³⁶ where the prevalence of Obesity in urban school children was found to be 11.0%. However, our study result was inconsistent with the study finding by Nazeem I. Sidddique et al ³⁷. which reported a prevalence of obesity as14.9%. In contrast to our study, Karimulla et al ³³ conducted a study where the combined prevalence of obesity and overweight was found to be 6.05%. Studies by S. Banerjee et al.³¹ and Bagudai S et al.³⁸ reported the prevalence of obesity among school going adolescents as 4.1% and 3.68% respectively. In our study, prevalence of obesity was higher among males 14(15.5%) as compared to 02(3.2%) females. This result was in accordance with study findings by Kar s et al.⁴² which showed a higher prevalence of obesity among males (12.4%) as compared to females (9.9%). However, Karimulla et al.³³ revealed a higher prevalence of obesity and overweight among females (7.5%) as compared to males (4.5%). The current study revealed a significant association between Obesity and HTN (p<0.05), which was in accordance to the study findings by Karimulla et al ³³, Anand et al ³⁵, Baradol RV et al.³⁹

The prevalence of Hypertension and Pre-Hypertension among adolescents in the present study was 7.2% and 5.3% respectively. This finding was in accordance with study findings by Anand et al³⁵ (HTN=7%), Chabra P et al.⁴⁰ (HTN=7.16%) and Gupta R et al.⁴¹ (HTN=7.2%). However, studies by Kumar P et al.³⁴ and Karimulla et al. ³³ found that the prevalence of HTN, pre-HTN among school going adolescents was (4.6%, 10.9 %); and (1.3% and 1.3%) respectively. Similarly, study by Rajnikanth BS et al.³⁰ revealed a low prevalence of HTN (2.6%) and pre-HTN (5.4%) among school going adolescents aged 12-16 years. In our study, prevalence of HTN in females (11.3%) was higher as compared to males (4.4%) in our study. This contrasted with the findings by Kumar P et al.³⁴ where males had a higher prevalence of HTN (5.0%) as compared to females (4.3%). Rajnikanth BS et al.³⁰ also revealed a higher prevalence of HTN among males (4.3%) as compared to females (0.8%). The present study revealed a higher prevalence of HTN among Obese (25%) and overweight (12.5%) participants as compared to subjects having healthy weight (1.2%), and found a significant association between obesity and HTN (p< 0.05). This finding was in accordance with results by Baradol RV et al.³⁹, Rajnikanth BS et al.³⁰, Kumar P et al.³⁴. Our study found no significant association between SES and HTN and this was consistent with the study findings by Rajnikanth BS et al.³⁰

Our study revealed that SBP (in percentile) (r=0.4) and DBP (in percentile) (r=0.5) had a significant positive correlation with weight (kg) of the study participants (p <0.001). Systolic BP in mm Hg (r=0.29) and Diastolic BP in mm Hg (r= 0.39) was also significantly correlated with age of participants with a p value of < 0.001. Positive correlation was found between DBP (in percentile) and height of the study participants (r=0.24, p<0.05). SBP (r=0.45) and DBP (r=0.42) also showed a significant positive correlation with BMI (kg/m²) (p<0.001). These results were in accordance with studies by Karimulla et al³³, Kumar P et al.³⁴ and Anand et al. ³⁵ 

Strengths of the study: Standard and validated methods were used for anthropometry and bp measurement of the participants. BMI of the study participants were calculated in percentiles. Systolic and Diastolic blood pressure were calculated in percentiles to determine the BP status of the subjects.

Limitations of the study: Sample size was small and included participants from a single urban slum (Jobra) of field practice area of SCB MCH Cuttack. Therefore, the study findings cannot be generalized to entire community or urban areas of Cuttack district. Chances of selection bias might be there. Genetics, behaviour, Yoga, meditation, psycho-social factors, underlying medical condition and other potential factors which affect BMI and BP of the study participants were not studied.

Obesity and hypertension are rising health problems and risk factors for cardio vascular and non-communicable diseases among adolescents in urban areas. Sedentary lifestyle, physical inactivity, unhealthy eating habits contribute to this rising trend. Health education, screening, dietary and lifestyle modification, Yoga, Meditation, stress management, regular health check- ups for early detection of risk factors should be encouraged in the schools and communities for prevention of emergence of chronic diseases later. Schools and its adjacent areas should be tobacco free zone. Use of gadgets like mobiles, laptops, and screen time should be limited along with promotion of outdoor games and sports. Adolescents may be included as a special group in population-based screening for obesity, HTN, risk factors for NCDs and can be assessed by ASHA and multipurpose health workers at grass root level using a checklist cum proforma. Also, there is a need for community participation, focussed interventions and policy formulation with special emphasis on restriction of advertisement and sale of alcohol, tobacco products, junk foods among adolescents along with implementation of health promotive measures, community awareness and disease preventive programs.

ADDITIONAL INFORMATION

Acknowledgements: We acknowledge the cooperation of study participants, field workers of Urban health and Training centre, SCB MCH, Jobra while conducting the research.

Conflict of Interest: None

Source of Funding: Self-funded, no financial support was received for the submitted work

1. Krishnaswamy, Vangal & Dudeja, Puja & Sashindran, V K. (2020). Obesity in School Children in India. 10.5772/intechopen.89602.
2. Nag K, Karmakar N, Saha I, Dasgupta S, Mukhopadhyay BP, Islam Mondal MR. An Epidemiological Study of Blood Pressure and Its Relation with Anthropometric Measurements among Schoolboys of Burdwan Municipal Area, West Bengal. Indian J Community Med. 2018 Jul-Sep;43(3):157-160. doi: 10.4103/ijcm.IJCM_232_17. PMID: 30294079; PMCID: PMC6166502.
3. Daniel RA, Haldar P, Prasad M, Kant S, Krishnan A, Gupta SK, Kumar R. Prevalence of hypertension among adolescents (10-19 years) in India: A systematic review and meta-analysis of cross-sectional studies. PLoS One. 2020 Oct 6;15(10): e0239929. doi: 10.1371/journal.pone.0239929. PMID: 33022021; PMCID: PMC7537899.
4. S, Seema & Kumari, Kusum & Kalyani, C. & Babbar, Prerna. (2021). Prevalence and contributing factors for adolescent obesity in present era: Cross‑sectional Study. Journal of Family Medicine and Primary Care. 10. 1890-1894. 10.4103/jfmpc.jfmpc_1524_20.
5. Kumar HNH, Mohanan P, Kotian S, Sajjan BS, Kumar SG. Prevalence of overweight and obesity among preschool children in semi urban South India. Indian Pediatr 2008; 45: 497-9
6. Wang Y, Chen HJ, Shaikh S, Mathur P. Is obesity becoming a public health problem in India? Examine the shift from under-nutrition to over-nutrition problems over time. Obes Rev 2009; 10 : 456-74
7. Khadilkar VV, Khadilkar AV, Cole TJ, Chiplonkar SA, Pandit D. Overweight and obesity prevalence and body mass index trends in Indian children. Int J Pediatr Obes 2011; 6 : e216-24.
8. Chhatwal J, Verma M, Riar SK. Obesity among preadolescent and adolescents of a developing country (India). Asia Pac J Clin Nutr 2004; 13 : 231-5.
9. Satyajit Bagudai, Pranati Nanda, Satyanath Reddy Kodidala. Pravalence of obesity and hypertension in Adolescent school going children of Berhampur, Odisha, India. International Journal of Physiotherapy and Research 2014;2: 777-80.
10. LeBlanc AG, Spence JC, Carson V, Connor Gorber S, Dillman C, Janssen I, et al. Systematic review of sedentary behaviour and health indicators in the early years (aged 0–4 years). Appl Physiol Nutr Metab 2012; 37: 753–72
11. Miller AL, Lumeng JC, LeBourgeois MK. Sleep patterns and obesity in childhood. Curr Opin Endocrinol Diabetes Obes 2015; 22: 41–7.
12. Ricardo V Garcia-Mayor, M Amalia Andrade, Monserrat Rios, Mary Lage, Carlos Dieguez, Felipe F Casanueva et al. Serum Leptin Levels in Normal Children: Relationship to Age, Gender, Body Mass Index, Pituitary-Gonadal Hormones and Pubertal Stage. Journal of Clinical Endocrinology and Metabolism; 82: 9.
13. Kuczmarski RJ, Flegal KM. Criteria for definition of overweight in transition: Background and recommendations for the United States. Am J Clin Nutr 2000; 72: 1074-1081.
14. Li X, Li S, Ulusoy E, Chen W, Srinivasan SR, Berenson GS. Childhood adiposity as a predictor of cardiac mass in adulthood: The Bogalusa Heart Study. Circulation 2004; 110: 3488–92.
15. Chadha SL, Tandon R, Shekhawat S, Gopinath N. An epidemiological study of blood pressure in school children (5-14 years) in Delhi. Indian Heart J. 1999;51:178–82.
16. Anand NK, Tandon L. Prevalence of hypertension in school going children. Indian Pediatr. 1996;33:377–81.
17. De Man SA, André JL, Bachmann H, Grobbee DE, Ibsen KK, Laaser U, et al. Blood pressure in childhood: Pooled findings of six European studies. J Hypertens. 1991;9:109–14. doi: 10.1097/00004872-199102000-00002.
18. Uhari M, Nuutinen EM, Turtinen J, Pokka T, Kuusela V, Akerblom HK, et al. Blood pressure in children, adolescents and young adults. Ann Med. 1991;23:47–51. doi: 10.3109/07853899109147930.
19. Yong LC, Kuller LH, Rutan G, Bunker C. Longitudinal study of blood pressure: Changes and determinants from adolescence to middle age. The Dormont High School follow-up study, 1957-1963 to 1989-1990. Am J Epidemiol. 1993;138:973–83. doi: 10.1093/oxfordjournals.aje.a116817.
20. Khan MI, Lala MK, Patil R, Mathur HN, Chauhan NT. A Study of the Risk Factors and the Prevalence of Hypertension in the Adolescent School Boys of Ahmedabad City. ;J Clin Diagn Res.2010 4:3348–54.
21. Attard SM, Herring AH, Howard AG, Gordon-Larsen P. Longitudinal trajectories of BMI and cardiovascular disease risk: The National Longitudinal Study of Adolescent Health. Obes Silver Spring Md. 2013 ;21:2180–8.
22. Tirosh A, Shai I, Afek A, Dubnov-Raz G, Ayalon N, Gordon B, et al. Adolescent BMI Trajectory and Risk of Diabetes versus Coronary Disease. N Engl J Med [Internet]. Massachusetts Medical Society; 2011;364:1315–25.
23. Sabri M, Gheissari A, Mansourian M, Mohammadifard N, Sarrafzadegan N. Essential hypertension in children, a growing worldwide problem. J Res Med Sci Off J Isfahan Univ Med Sci . 2019;24.
24. Bell Cynthia S., Samuel Joyce P., Samuels Joshua A. Prevalence of hypertension in children. Hypertension. 2019 ;73:14852.Availablefrom: https://www.ahajournals.org/doi/full/10.1161/HYPERTENSIONAHA.118.11673. pmid:30571555
25. Xiaoli Chen, Youfa Wang. Tracking of Blood Pressure From Childhood to Adulthood. Circulation. 2008;117:3171–80. Available from: https://ahajournals.org/doi/10.1161/circulationaha.107.730366
26. Saha I, Paul B, Dasgupta A. Prevalence of hypertension and variation of blood pressure with age among adolescents in Chetla, India. Tanzan J Health Res. 2008;10:108–11. doi: 10.4314/thrb.v10i2.14349. 
27. Data Table of BMI-for-Age Charts. Body Mass Index for Age Tables, Children Ages 2-20 Years Selected Percentiles. 2000. Available from: http://www.cdc.gov/growthcharts/html_charts/bmiagerev.htm
28. USA: National Institute of Health; 2005. US department health and human services, National Institute of Health, National Heart, Lung and Blood Institute. The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents; pp. 5–7.
29. Calculators: weight unit conversions—MSD manual professional edition. https://www.msdmanuals.com/professional/multimedia/clinical-calculator/Weight Unit Conversions
30. Rajinikanth, Suba & U, Sujatha & Yadav, Sankalp. (2023). Prevalence of Obesity and Its Relationship With Hypertension Among School-Going Adolescents Aged 12–16 Years. Cureus. 15. 10.7759/cureus.42999.
31. Banerjee, Sitikantha & Khan, Mubashshera & Bandyopadhyay, Kajari & S, Kalaiselvi & Deshmukh, Pradeep. (2021). Hypertension and its determinants among school going adolescents in selected urban slums of Nagpur city, Maharashtra: A cross-sectional study. Clinical Epidemiology and Global Health. 12. 100832. 10.1016/j.cegh.2021.100832.
32. Patil, A. D., Shejul, S., Bhandarkar, P., Kattimani, A., Mudassir, A., & Bantwal, K. (2018). A study of adolescent obesity and hypertension in urban school in Mumbai. International Journal Of Community Medicine And Public Health, 5(2), 790–794. https://doi.org/10.18203/2394-6040.ijcmph20180270
33. Karimulla S, Rao PN. Prevalence of obesity and hypertension in adolescent school children of Guntur town, Andhra Pradesh. International Journal of Contemporary Medical Research 2021;8(7): G1-G4.
34. Kumar P, Kumar D, Ranjan A, Singh CM, Pandey S, Agarwal N. Prevalence of Hypertension and its Risk Factors Among School Going Adolescents of Patna, India. J Clin Diagn Res. 2017 Jan;11(1):SC01-SC04. doi: 10.7860/JCDR/2017/23886.9196. Epub 2017 Jan 1. PMID: 28274012; PMCID: PMC5324457.
35. Anand T, Ingle GK, Meena GS, Kishore J, Kumar R. Hypertension and its correlates among school adolescents in delhi. Int J Prev Med. 2014 Mar;5(Suppl 1):S65-70. PMID: 24791194; PMCID: PMC3990918.
36. Mohan B, Verma A, Singh K, Singh K, Sharma S, Bansal R, Tandon R, Goyal A, Singh B, Chhabra ST, Aslam N, Wander GS, Roy A, Prabhakaran D. Prevalence of sustained hypertension and obesity among urban and rural adolescents: a school-based, cross-sectional study in North India. BMJ Open. 2019 Sep 8;9(9):e027134. doi: 10.1136/bmjopen-2018-027134. PMID: 31501100; PMCID: PMC6738741.
37. Nazeem I. Siddiqui, Mrs. S. Bose. Prevalence and trends of obesity in Indian school children of different socioeconomic class. Ind J of Basic & Applied Medical Res. 2012; 5: 393 – 8.
38. Bagudai S, Nanda P,  Kodidala SR.  Prevalence Of Obesity  &  Hypertension  In  Adolescent  School Going  Children  Of  Berhampur,  Odisha,  Quick Response code. 2014;2(6):777–80
39. Baradol RV, Patil S, Ranagol A. Prevalence of overweight, obesity and hypertension amongst school children and adolescents in North Karnataka: A cross sectional study. Int J Med Public Health 2014;4:260-4
40. Chhabra P, Grover VL, Aggarwal K, Kannan AT. Nutritional status and blood pressure of medical students in Delhi. IJCM. 2006;31:10–2.
41. Gupta R, Goyle A, Kashyap S, Agarwal M, Consul R, Jain BK. Prevalence of atherosclerosis risk factors in adolescent school children. Indian Heart J. 1998;50:511–5.
42. Kar S, Khandelwal B. Fast foods and physical inactivity are risk factors for obesity and hypertension among adolescent school children in east district of Sikkim, India. J Nat Sci Biol Med. 2015 Jul-Dec;6(2):356-9. doi: 10.4103/0976-9668.160004. PMID: 26283829; PMCID: PMC4518409.