Childhood obesity and its associated comorbidity, hypertension, have emerged as major global health challenges. This issue affects many low- and middle-income countries, where lifestyle changes have contributed to rising obesity rates.1–3 The increasing prevalence of obesity in children has been accompanied by a global rise in pediatric hypertension, which can lead to organ damage and even mortality if left untreated. Worldwide, prehypertension is estimated to affect 6% of girls and 14% of boys, while hypertension prevalence ranges from 3–4%.4–6 In developing countries, childhood hypertension remains an underrecognized problem. In India, few national-level studies exist on the prevalence of obesity and hypertension in children, and most available data are from school-based studies. Reported prevalence of pediatric hypertension in India ranges between 2–5%.7 Despite the availability of proven management strategies for childhood obesity and hypertension, early diagnosis is critical to enabling timely intervention and improved outcomes.8-11 This study aims to estimate the prevalence of obesity and hypertension among school children and to examine the relationship between blood pressure and various body fat indices, including BMI, waist circumference (WC), waist-to-height ratio (WHtR), and triceps skinfold thickness (TSFT). The findings will contribute to early identification and intervention strategies for pediatric hypertension and obesity.

Study Design This was a community-based cross-sectional study. Study Area The study was conducted in selected schools from urban and rural areas of Chittoor district. Schools were stratified as government and private, and children were randomly selected from each category using simple random sampling proportional to school size. Study Duration The study was conducted over 18 months. Inclusion Criteria • All apparently healthy school children aged 10–16 years whose parents provided informed consent. Exclusion Criteria 1. Children below 10 years or above 16 years. 2. Children with a known history of cardiac, endocrine, or renal diseases. Sample Size The required sample size was 300, calculated with p = 6.5%, q = 93.5%, and L = 3 at 95% confidence interval. A total of 854 schoolchildren were examined. For survey-based quantitative research and due to limited literature on body fat indices, the sample population was divided into rural and urban groups, each representing the target population proportionally. Methodology Children from both government and private schools in rural and urban areas of Chittoor district were included. Six schools were selected to cover all subgroups. Prior permissions were obtained from education and health authorities as well as school principals. Informed consent was obtained from parents, and the study was conducted during school hours. A structured questionnaire was sent to parents through children’s diaries, and data collection was supported by school teachers and local ASHA workers. Anthropometric measurements and blood pressure readings were performed according to standardized protocols. Anthropometric Measurements Weight: Measured using a digital weighing scale to the nearest 0.1 kg, with children wearing light clothing and no shoes. Height: Measured using a non-stretchable metallic tape fixed to the wall. Children stood erect with heels, buttocks, shoulders, and occiput against the wall. Measurements were recorded to the nearest 0.1 cm. Waist Circumference (WC): Measured at the midpoint between the iliac crest and the lower margin of the last palpable rib in the mid-axillary line, with the child standing upright after several normal breaths. Body Mass Index (BMI): Calculated using the formula: Body mass index (BMI) BMI was calculated using the formula BMI= Weight (in Kg)/ Height (in meter2) BMI was classified according to WHO Z-scores for children aged 5–19 years: • Obese: > +2Z • Overweight: > +1Z • Normal: +1Z to -2Z • Thinness: < -2Z • Severe thinness: < -3Z Waist-to-height ratio (WHtR) Waist to height ratio calculated using the formula WHtR=Waist circumference (in meters)/Height (in meters) Triceps Skinfold Thickness (TSFT): Measured using Harpenden calipers over the triceps region. Blood Pressure Measurement Blood pressure (BP) was measured using a mercury sphygmomanometer on the right arm in a sitting position, with the cubital fossa supported at heart level. Three readings were taken at 10-minute intervals, and the mean value was considered. • Hypertension: SBP or DBP ≥ 95th percentile for age, sex, and height on ≥3 occasions. o Stage 1: BP > 95th to 99th percentile o Stage 2: BP > 99th percentile • Prehypertension: SBP or DBP between the 90th and 95th percentile for age, sex, and height Statistical Analysis Data were analyzed using SPSS v24.0 and R software. Nominal data were log-transformed as needed. Statistical methods included multivariate linear regression, Pearson and Spearman correlation, paired and unpaired t-tests, and Chi-square analysis. Receiver operating characteristic (ROC) analysis and control charts were used to evaluate predictors. A p-value < 0.01 was considered statistically significant.

A total of 860 children were enrolled in the study, of which 6 children were excluded due to incomplete data. Thus, 854 children were included in the final analysis. Demographic Characteristics Out of 854 children: • 410 (48%) were from rural areas and 444 (52%) were from urban areas. • In rural areas, 209 (50.97%) were males and 201 (49.03%) were females. • In urban areas, 214 (48.19%) were males and 230 (51.81%) were females. School Type Distribution: • Rural: 184 (44.87%) in government schools, 226 (55.13%) in private schools • Urban: 197 (44.36%) in government schools, 247 (55.64%) in private schools • Overall: 381 (44.61%) in government schools, 473 (55.39%) in private schools Nutritional Status According to WHO BMI charts: • Obese: 15 (1.76%) • Overweight: 53 (6.21%) • Thin: 129 (15.10%) • Severely thin: 53 (6.21%) Sex-wise distribution: • Females: Obese 1.41%, Overweight 6.96%, Thin 13.68%, Severely thin 4.41% • Males: Obese 2.14%, Overweight 5.44%, Thin 16.54%, Severely thin 8.04% Area-wise distribution: • Rural: Obese 2.2%, Overweight 6.58%, Thin 13.66%, Severely thin 6.10% • Urban: Obese 1.36%, Overweight 5.85%, Thin 16.44%, Severely thin 6.31% Hypertension and Prehypertension Among 854 children: • Hypertensive: 19 (2.23%) • Prehypertensive: 23 (2.69%) Sex-wise distribution: • Females: Hypertensive 2.32%, Prehypertensive 3.25% • Males: Hypertensive 2.13%, Prehypertensive 2.13% Hypertensive children were almost equally distributed between sexes: 10 females (52.63%) and 9 males (47.37%). Area-wise distribution: • Rural: Hypertensive 2.68%, Prehypertensive 3.17% • Urban: Hypertensive 1.80%, Prehypertensive 2.25% Hypertensive children by area: 11 (57.89%) from rural areas and 8 (42.11%) from urban areas. Prehypertensive children by area: 13 (56.52%) rural, 10 (43.48%) urban. School-wise distribution: • Rural government schools: Hypertensive 1.63%, Rural private schools: 3.54% • Urban government schools: Hypertensive 2.54%, Urban private schools: 1.22% Hypertension and Obesity Relationship Among obese children (n = 15): • Hypertensive: 7 (46.67%) • Prehypertensive: 5 (33.33%) • Normotensive: 3 (20%) Among overweight children (n = 53): • Hypertensive: 18 (15.1%) • Prehypertensive: 9 (16.98%) • Normotensive: 36 (67.92%) School-specific distribution of obese children with hypertension: • Rural government: 50% hypertensive, 50% normotensive • Rural private: 42.9% hypertensive, 42.9% prehypertensive, 14.2% normotensive • Urban government: 100% hypertensive • Urban private: 40% hypertensive, 40% prehypertensive, 20% normotensive Correlation of Body Fat Indices with Blood Pressure Scatter plot analysis (95% confidence interval) revealed: • Waist circumference (WC) positively correlated with both systolic BP (SBP) and diastolic BP (DBP). • Triceps skinfold thickness (TSFT) also positively correlated with SBP and DBP. • BMI, WC, waist-to-height ratio (WHtR), and TSFT were all significantly and positively correlated with SBP and DBP (p < 0.001). • The strongest positive correlation with SBP and DBP was observed with BMI. This positive correlation was consistent across sexes and both rural and urban populations. ROC Curve Analysis Systolic BP: • BMI: AUC 0.786 • WC: AUC 0.763 • WHtR: AUC 0.625 • Conclusion: BMI and WC were better predictors of high SBP than WHtR. Diastolic BP: • BMI: AUC 0.686 • WC: AUC 0.729 • WHtR: AUC 0.637 • Conclusion: WC had the highest predictive ability for high DBP among the three indices. Table 1: Age wise distribution of children in different areas Sl No. Years Rural area Urban area Total Number(n) % Number(n) % Number(n) % 1 10 60 14.63 68 15.32 128 14.99 2 11 63 15.37 72 16.22 135 15.81 3 12 64 15.61 67 15.09 131 15.34 4 13 59 14.39 63 14.19 122 14.28 5 14 61 14.87 64 14.41 125 14.64 6 15 62 15.13 64 14.41 126 14.75 7 16 41 10 46 10.36 87 10.19 Total 410 100.0 444 100.0 854 100.0 Table 2: Distribution of children in different sex based on BMI status Female Male Total (n) Number of children (n) Percent (%) Number of children (n) Percent (%) Obese 6 1.41 9 2.14 15 Overweight 30 6.96 23 5.44 53 Normal 317 73.54 287 67.84 604 Thinness 59 13.68 70 16.54 129 Severe thinness 19 4.41 34 8.04 53 Grand Total 431 100.0 423 100.0 854 Table 3: Distribution of children in different areas based on BMI status BMI Status Rural area Urban area Total (n) Number of children (n) Percent(%) Number of children Percent (%) Obese 9 2.20 6 1.36 15 Overweight 27 6.58 26 5.85 53 Normal 293 71.46 311 70.04 604 Thinness 56 13.66 73 16.44 129 Severe thinness 25 6.10 28 6.31 53 Total 410 100.0 444 100.0 854 Table 4: Distribution of children based on BMI status in different schools BMI Rural area Urban area Total (n) Government School Private School Government School Private School n % n % n % n % Obese 2 1.09 7 3.10 1 0.51 5 2.02 15 Overweight 9 4.89 18 7.96 7 3.55 19 7.69 53 Normal 139 75.54 154 68.15 152 77.16 159 64.37 604 Severe thinness 22 11.96 34 15.04 24 12.18 49 19.84 129 Thinness 12 6.52 13 5.75 13 6.60 15 6.08 53 Grand Total 184 100.0 226 100.0 197 100.0 247 100.0 854 Table 5: Distribution of obesity and overweight children in different age groups AGE Obese children Overweight children Female Male Female Male 10 1 1 2 3 11 2 2 6 3 12 2 3 2 4 13 0 0 3 3 14 1 2 6 5 15 0 0 8 3 16 0 1 3 2 Table 6: Distribution of children in different sex based on BP status Blood pressure status Female Male Total (n) Number of children (n) Percent (%) Number of children (n) Percent (%) Hypertensive 10 2.32 9 2.13 19 Pre hypertensive 14 3.25 9 2.13 23 Normal 407 94.43 405 95.74 812 Grand Total 431 100.0 423 100.0 854 Table 7: Distribution of children in different schools based on BP status BP status Rural area Urban area Grand Total (n) Government school Private school Government school Private school n % n % n % n % Hypertensive 3 1.63 8 3.54 5 2.54 3 1.22 19 Pre hypertensive 1 0.54 12 5.31 3 1.52 7 2.83 23 Normal 180 97.83 206 91.15 189 95.94 237 95.95 812 Grand Total 184 100.0 226 100.0 197 100.0 247 100.0 854 Table 8: Distribution of children in different age groups based on Blood Pressure status AGE Hypertensive children Pre hypertensive children Female Male Female Male 10 0 0 3 1 11 2 2 1 1 12 1 2 1 1 13 1 0 4 1 14 3 3 3 2 15 2 1 1 2 16 1 1 1 1 Table 9: Distribution of rural area children based on BP status in different nutritional grades BMI status Rural Area Government school children Total (n) Private school children Total (n) HTN n(%) Pre HTN n(%) Normal n(%) HTN n(%) Pre HTN n(%) Normal n(%) Obese 1 (50) 0(0) 1 (50) 2 3 (42.9) 3 (42.9) 1 (14.2) 7 Overweight 2 (22.2) 1 (11.1) 6 (66.7) 9 3 (16.6) 3 (16.6) 12 (66.8) 18 Normal 0(0) 0(0) 139 (100) 139 2 (1.3) 4 (2.6) 148 (96.1) 154 Thinness 0(0) 0(0) 22 (100) 22 0(0) 2 (5.9) 32 (94.1) 34 Severe Thinness 0(0) 0(0) 12 (100) 12 0(0) 0(0) 13 (100) 13 Table 10: Distribution of female and male children based on BP status in different nutritional grades Female Male HTN n(%) Pre HTN n(%) Normal n(%) Total n HTN n(%) Pre HTN n(%) Normal n(%) Total n Obese 3 3 0(0) 6 4 2 3 9 (50) (50) (44.4) (22.2) (33.4) Overweight 4 6 20 30 4 3 16 23 (13.4) (20) (66.6) (17.4) (13) (69.6) Normal 2 4 311 317 1 3 283 287 (0.63) (1.26) (98.1) (0.3) (1.1) (98.6) Thinness 0(0) 1 58 59 0(0) 1 69 70 (1.7) (98.3) (1.4) (98.6) Severe 1 0(0) 18 19 0(0) 0(0) 34 34 Thinness (5.3) (94.7) (100) Table 11: Descriptive Statistics of total children in our study N Minimum Maximum Mean SD Age 854 10 16 12.68 1.918 Weight 854 17.4 76.9 36.915 10.305 Height 854 1.16 1.78 1.472 0.114 WC 854 0.47 0.96 0.69 0.088 BMI 854 9.92 29.37 16.755 3.140 WHtR 854 0.33 0.66 0.47 0.045 Triceps Skin fold thickness 854 5.04 22.21 12.31 3.64 SBP 854 84 130 101.65 6.559 DBP 854 50 88 64.18 5.15 Table 12. Pearson correlation coefficient (r) of different body fat indices and hypertension in children Body fat indices SBP DBP BMI Pearson correlation(r) 0.544 0.465 P-value <0.0001 <0.0001 N 854 854 Waist circumference Pearson correlation(r) 0.524 0.456 P-value <0.0001 <0.0001 N 854 854 Waist-to-height ratio Pearson correlation(r) 0.374 0.382 P-value <0.0001 <0.0001 N 854 854 Triceps Skin fold thickness Pearson correlation(r) 0.276 0.208 P-value <0.0001 <0.0001 N 854 854 Table 13. AUC- Test result variable(s) Asymptomatic 95% confidence interval Area Std Errora Asymptomatic Sig.b Lower bound Upper bound BMI 0.786 0.026 0.00 0.734 0.830 WC 0.763 0.024 0.00 0.718 0.796 WHtR 0.625 0.035 0.11 0.578 0.683

Obesity in children is increasingly recognized as a precursor to various metabolic and cardiovascular conditions that often manifest later in life. This prompted our study to investigate the prevalence of obesity and hypertension in school-aged children and to examine their relationship with various body fat indices. Study Population A total of 860 children were initially enrolled, with 6 excluded due to incomplete data or known renal and cardiac conditions. The final analysis included 854 children aged 10–16 years, with a mean age of 13.3 years. Among them, 423 were males (mean age 10.67 years) and 431 were females (mean age 10.68 years). Of the participants, 410 children were from rural areas and 444 from urban areas. School-wise distribution included 184 children in rural government schools, 226 in rural private schools, 197 in urban government schools, and 247 in urban private schools. Prevalence of Overweight and Obesity National-level studies on childhood obesity in India are limited. In our study, obesity prevalence was 1.36% in urban regions and 2.20% in rural regions. Baradol et al.10 reported 3.4% obesity in urban children versus 0.5% in rural children, though their rural cohort was geographically isolated from metropolitan areas. George et al.11 observed 16% overweight and 7% obesity among rural adolescents. Obesity prevalence was higher in private schools, consistent with our findings: 5.12% in private schools versus 1.60% in government schools. This is comparable to Cherian et al., who reported 7.5% obesity in private schools and 1.5% in government schools. Gender-wise, 5.44% of males and 6.96% of females were overweight, similar to Baradol et al. (males 5.6%, females 5.7%). Prevalence of Hypertension Data on pediatric hypertension in India is limited. In our study, hypertension prevalence was 2.13% in males and 2.32% in females. These findings are comparable to Bankar Chirag et al.,12 who reported 3.22% in males and 3.16% in females, and Buch et al.,13 who reported higher prevalence in boys (6.74%) than girls (6.13%), likely due to their focus on metropolitan populations. Prevalence of Prehypertension Few studies have evaluated prehypertension in Indian children. Our study found an overall prevalence of 2.69%, with 2.13% in males and 3.25% in females, and 3.2% in rural versus 2.1% in urban children. School-wise, prehypertension was present in 1.32% of government school children and 3.68% of private school children. These findings align with Narayanappa et al.,14 who reported prehypertension in 2.8% of rural and 2.9% of urban children. Correlation between Body Fat Indices and Hypertension While numerous studies in adults have shown associations between body fat indices and hypertension, data for Indian children remain scarce. Our study found a positive correlation between BMI, WC, and WHtR with both SBP and DBP. Among obese children, 36.8% were hypertensive and 42.1% overweight children were hypertensive. These findings are consistent with NA Kajale et al.,15 who reported similar correlations. High correlation coefficients were observed for BMI with SBP (r = 0.54) and DBP (r = 0.46), indicating a stronger association compared to WC and WHtR. ROC curve analysis confirmed that BMI, WC, and WHtR are effective predictors of elevated blood pressure, with AUCs as follows: • SBP: BMI 0.78, WC 0.76, WHtR 0.62 • DBP: BMI 0.68, WC 0.72, WHtR 0.63 WC demonstrated a slightly stronger discriminatory ability for high DBP. These results were consistent across sexes and urban-rural populations, suggesting that simple anthropometric measures like BMI, WC, and WHtR can reliably identify children at risk of elevated BP. A waist-to-height ratio cutoff of 0.528 (p < 0.01) was found to detect elevated SBP and DBP with 15% sensitivity, 90% specificity, 32% positive predictive value, and 97% negative predictive value. Implications Markers of body fat such as BMI, WC, TSFT, and WHtR can be used in routine school-based screenings to identify children at risk for hypertension. These measurements are simple, non-invasive, and feasible in resource-limited settings. Children identified with nutritional issues (obesity, overweight, thinness) or elevated blood pressure were appropriately monitored and managed through collaboration with parents, teachers, ASHA workers, and local health authorities.

In this study, the overall prevalence of obesity among children was 1.76%, and the prevalence of hypertension was 2.23%. Body fat indices—including Body Mass Index (BMI), Waist Circumference (WC), Waist-to-Height Ratio (WHtR), and Triceps Skin Fold Thickness (TSFT)—showed a positive correlation with both Systolic and Diastolic Blood Pressure. An increase in these body fat indices was associated with a corresponding increase in blood pressure. No statistically significant associations were observed between hypertension and the child’s sex, residential area (urban or rural), or type of school (government or private). These findings emphasize the importance of routine blood pressure measurements as part of pediatric clinical examinations. Clinicians should maintain a high index of suspicion for hypertension in overweight and obese children. In addition to measuring weight and height, it is recommended to routinely assess waist circumference and skin fold thickness to better identify children at risk for elevated blood pressure.

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