European Journal of Clinical Nutrition (1999) 53, 333±337
ß 1999 Stockton Press. All rights reserved 0954±3007/99 $12.00
http://www.stockton-press.co.uk/ejcn
Sex-related in¯uence of body size and sexual maturation on
blood pressure in adolescents
G Leccia1, T Marotta2, MR Masella1, G Mottola3, G Mitrano3, F Golia1, P Capitanata1, L Guida2,
F Contaldo2 and LA Ferrara2*
1
Servizio di Dietologia ASL Caserta 2, Italy; 2Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy;
and 3Dipartimento Materno-Infantile ASL Caserta 2, Italy
Objective: This study is aimed at investigating the in¯uence of body size, body fat and sexual maturation on
blood pressure (BP) in adolescents.
Design: A cross-sectional study.
Setting: A suburban student population of Southern Italy.
Subjects: One hundred ninety students attending the ®rst and second year of a secondary school. Five were
excluded because they were affected by major diseases. The remaining were 98 M and 87 F (mean age for either
group ˆ 12.0 0.8 y).
Methods: Blood pressure was measured by a mercury sphygmomanometer, body weight by a platform beamscale, other measurements included height, biceps, triceps, subscapular and suprailiac skinfolds by a caliper;
sexual maturation was evaluated according to Tanner.
Results: Body size was greater than in Tanner's population: in particular body weight (but not height) in our
sample markedly exceeded that of the children of the same age in Tanner's population. Boys had higher systolic
blood pressure (SBP) than girls (BP ˆ 109=64 12=10 vs 103=63 11=8 mmHg, P < 0.02 for SBP), while heart
rate and waist=hip ratio were lower.
During puberty Ð evaluated on the basis of pubic hair growth Ð BP in girls was higher than in the prepubertal
phase (107=66 9=7 vs 99=61 10=7, P < 0.01). Pubertal boys showed a reduced percent of body fat (calculated
from four skinfold measurements) in comparison to prepubertal ones (21.0% 4.5 vs 24.5% 7.1, P < 0.01). In
linear correlation analysis, height, BW, BMI and lean body mass were found to be signi®cantly associated with
SBP in both sexes and to diastolic blood pressure (DBP) in girls. Percent body fat was correlated with SBP in
boys, while sexual maturation was associated to SBP and DBP in girls only.
Multiple regression analysis indicated a signi®cant contribution of body size to BP variability, particularly in
the girls. Sexual maturation was excluded from the ®nal regression equations when height, BW or lean body
mass were present.
Conclusions: These data indicate that body weight in these adolescents is greater that in Tanner's population of
the same age and sex. Body size appears to be a major determinant of BP, whereas sexual maturation seems to
in¯uence BP levels mainly through body growth. The in¯uence of percent body fat on BP setting seems to be of
limited importance.
Descriptors: blood pressure; sexual maturation; body size; lean body mass; body fat; childhood; obesity
Introduction
The prevalence of overweight or frank obesity among
children has been found to be relatively higher in Southern
Europe than in other countries (Locard et al, 1992). In
North-Eastern Italy the average is 30% at the age of 12 y
(Maffeis et al, 1993), but it is even higher in the South, as
shown by a study performed in a 10 y old children population living in Naples (Esposito-Del Puente et al, 1996). The
relationship between body weight (BW) and some so-called
`metabolic risk factors', ®rstly arterial hypertension, is well
*Correspondence: Dr LA, Ferrara, Department of Clinical and
Experimental Medicine, Federico II University Via S. Pansini 5, 80131,
Naples, Italy.
Received 14 August 1998; revised 20 November 1998; accepted
1 December 1998
documented in adults; there is also evidence that BW is
able to in¯uence blood pressure (BP) levels during
childhood, at least in baseline conditions (Ferrara et al,
1989). Pathophysiological speculations imply that the impairment of insulin sensitivity or adrenergic nervous system
activity are responsible for the relationship observed (Julius
& Johnson, 1985; Philipp et al, 1978; Ferrannini et al, 1987).
The problem is even more intriguing during childhood, since
the in¯uence of sexual maturation on BP levels should also be
considered (Tanner & Whitehouse, 1976; Vartiainen et al,
1986; Daniels et al, 1996).
This present study, performed in a school population
(age range 10 ± 14 y), aimed at detecting the in¯uence of
body size and sexual maturation on BP regulation.
Patients and methods
The study group was composed of one hundred ninety
students attending the ®rst and second year of a secondary
Body size=sexual maturation and blood pressure
G Leccia et al
334
school in the village of Carinaro, located in the surroundings of Caserta (Campania, Southern Italy). Five of them
were excluded because affected by major diseases (one
student for pituitary nanism, one for haemophilia, one for
secondary obesity, one for hemicolectomy and one for
testicle removal due to unknown causes). Of the remaining
185 students, 87 (55 M, 32 F, mean age 11.5 0.6 y)
attended the ®rst and 98 (43 M, 55 F, mean age
12.5 0.7 y) the second year. The study was approved by
the School Council and the students were included after the
informed consent of their parents.
Students were seen in the medical of®ce of the school;
sitting BP was measured after a 10 min rest in a quiet and
warm environment with a mercury sphygmomanometer,
according to the guidelines for pressure control in childhood
(Report of the Second task force on blood pressure control
in children, 1987), by two experienced observers previously
certi®ed and trained to obtain an intraobserver difference
below 5%. A pediatric cuff (16610 cm) was used when
necessary. Body weight (BW) was measured with the
students wearing underwear clothing, using a platform
beam-scale (SECA 760). Height was measured with the
students standing without shoes. Body mass index (BMI)
was calculated as weight (kg) by squared height (m2).
Waist and hip circumference were also determined and
waist-to-hip ratio calculated (W=H). Skinfold thickness
(biceps, triceps, subscapular and suprailiac skinfolds) was
measured with a caliper on the left side of the body (Holtan
LTD, Crynych, UK) according to well-validated standard
techniques. Percent body fat was calculated on the basis of
the thickness of the four skinfolds, according to Deurenberg
et al (1991). The lean body mass was calculated as the
difference between BW and body fat.
Sexual maturation was evaluated on the basis of pubic
hair growth according to Tanner, the students were divided
into ®ve classes, according to the results (P1 ± P5) (Tanner
& Whitehouse, 1976).
Statistical analysis
Data were expressed as mean standard deviations. Statistical analysis was performed by unpaired Student t and w2tests. The in¯uence of independent variables on BP was
investigated by linear correlation, Spearman rank correlation and multiple stepwise regression analysis using SPSS
statistical package. In performing this last analysis, the
independent variables were automatically entered starting
from the one with the most powerful association with the
dependent variable. The SPSS statistical package was used
for calculations (Nie et al, 1975).
Results
Of the 185 students examined, 98 were boys and 87 girls;
mean age of the study group was 12 0.8 y. Anthropometric characteristics of the study population are
shown in Table 1. Boys had signi®cantly higher systolic
blood pressure (SBP) levels and W=H, and lower heart rate
(HR) than girls.
Figures 1 and 2 show a comparison of the 25th, 50th,
and 75th height and weight percentiles of our study group
(age 11 ± 13 y) with the corresponding data from Tanner's
sample (Tanner & Whitehouse 1976). Values of stature
percentiles in our study population were similar or higher
than in Tanner's, depending on age and sex. A huge
difference in the value of weight percentiles between
Table 1 Blood pressure and anthropometric characteristics of the
students according to sex
Age (y)
Height (cm)
Weight (Kg)
BMI (kg=m2)
SBP (mmHg)
DBP (mmHg)
HR (beats=min)
Waist (cm)
Hip (cm)
W=H
Biceps skinfold (cm)
Triceps skinfold (cm)
Subscapular skinfold (cm)
Suprailiac skinfold (cm)
% fat
Boys
(n ˆ 98)
Girls
(n ˆ 87)
12.0 0.8
148.9 7.8*
49.0 11.6
22.0 4.1
109.4 11.8**
63.9 10.1
81.6 9.8***
72.4 10.6***
82.2 9.4
0.88 0.05***
12.1 7.0*
21.7 9.2
16.1 10.3
16.7 12.2
23.8 6.8
12.0 0.8
151.3 7.6
49.1 11.0
21.2 3.5
103.4 10.8
63.4 7.8
88.3 10.5
67.7 10.8
83.9 12.7
0.80 0.04
10.3 4.6
21.7 8.0
17.1 9.0
15.1 9.0
24.9 5.3
Signi®cances: *P < 0.05; **P < 0.02; ***P < 0.001.
BMI ˆ body mass index; SBP ˆ systolic blood pressure; DBP ˆ diastolic
blood pressure; HR ˆ heart rate; W=H ˆ waist-to-hip ratio; % fat ˆ percent
body fat.
Figure 1 25th, 50th, and 75th percentile of height and body weight in boys, compared with similar values in boys of the same age in Tanner's population.
Body size=sexual maturation and blood pressure
G Leccia et al
335
Figure 2 25th, 50th, and 75th percentile of height and body weight in girls, compared with similar values in girls of the same age in Tanner's population.
We have, subsequently, investigated the possible relationships between BP and the anthropometric characteristics of the students. Height, BW, and BMI were
signi®cantly related to SBP in both sexes and to diastolic
blood pressure (DBP) in the female subgroup only, as
shown by linear correlation analysis. A signi®cant correlation was found between calculated lean body mass and SBP
and DBP in girls. Lean body mass was also correlated with
SBP in boys. Percent body fat was signi®cantly related to
SBP in the boys. The relationship between BP and sexual
maturation, investigated by the Spearman rank correlation,
was found to be signi®cant in girls only (Table 3).
The independent in¯uence of these variables on BP was
evaluated by stepwise multiple regression analysis. Students were divided into quartiles of age, height, BW, BMI
and percent body fat. For these variables the value of the
corresponding quartile was assigned to each student: these
values were used, along with the stage of sexual maturation
(1 ± 4), in the multiple regression analysis. Different models
were tested, all of them including age and sexual
groups was present in all sex and age subgroups, our data
being well above those from Tanner's. The value of the
50th percentile of weight in our sample is close to the 97th
percentile for boys and to the 75th percentile for girls of
Tanner's study group, at 12 y of age.
Students were divided into those in prepubertal (P1 ± P2)
and pubertal phase (P3 ± P4), no-one being in the last stage
of sexual maturation (P5): 77 boys were prepubertal and
only 21 pubertal. On the opposite, most of girls were in the
pubertal phase (n ˆ 48) and only 39 were prepubertal.
Among boys, puberty mainly affected percent body fat
which was signi®cantly reduced in the pubertal phase. SBP
and HR were higher in pubertal boys than in prepubertal
ones. These differences, however, did not reach statistical
signi®cance (Table 2, left). At variance, BP was signi®cantly higher in the subgroup of pubertal girls, as compared
to prepubertal ones. Percent body fat was slightly, but not
signi®cantly, lower in pubertal girls, who also showed a
signi®cantly lower W=H than the prepubertal ones (Table
2, right).
Table 2 Blood pressure and anthropometric characteristics of male (on the left) and female (on the right) students
according to puberty
Boys
Age (y)
Height (cm)
Weight (Kg)
BMI (kg=m2)
SBP (mmHg)
DBP (mmHg)
HR (beats=min)
Waist (cm)
Hip (cm)
W=H
Biceps skinfold (cm)
Triceps skinfold (cm)
Subscapular skinfold (cm)
Suprailiac skinfold (cm)
% fat
Girls
Prepubertal
(n ˆ 77)
Pubertal
(n ˆ 21)
Prepubertal
(n ˆ 39)
Pubertal
(n ˆ 48)
11.7 0.7
146.7 6.4
47.3 11.0
21.9 4.1
108.8 12
64.1 9.6
80.9 9.2
71.8 10.5
81.4 7.1
0.88 0.5
12.5 7.1
21.9 9.4
16.1 10.4
16.5 11.8
24.5 7.1
12.9 0.8***
156.7 7.3***
55.0 11.0***
22.4 4.3
111.6 11
63.3 12.1
84.0 11.6
74.5 11.1
85.4 7.4
0.87 0.7
10.6 6.4
20.7 8.7
15.9 9.9
17.3 13.7
21.0 4.5**
11.6 0.7
147.3 7.7
44.5 11
20.3 3.4
98.8 10.5
60.8 7.5
87.4 9.3
64.3 14.0
79.2 15.9
0.81 0.4
9.9 4.8
20.7 8.2
15.3 8.4
13.0 8.5
26.1 5.9
12.3 0.7***
154.7 5.7***
52.8 9.5***
22.0 3.4*
107.2 9.5***
65.6 7.5**
89.1 11.4
68.5 6.8
87.6 7.8
0.78 0.4**
10.6 4.5
22.6 7.9
18.7 9.3
16.8 9.2*
24.0 4.5
Signi®cances: *P < 0.05; **P < 0.01; ***P < 0.001.
BMI ˆ body mass index; SBP ˆ systolic blood pressure; DBP ˆ diastolic blood pressure; HR ˆ heart rate,
W=H ˆ waist-to-hip ratio; % fat ˆ percent body fat.
Body size=sexual maturation and blood pressure
G Leccia et al
336
Table 3 Correlation matrix between systolic=diastolic blood pressure
(SBP=DBP) and age, height (Ht), body weight (BW), body mass index
(BMI), lean body mass (LBM), percent body fat (% Fat) and sexual
maturation (SM) in male and female students
Boys
Age
Ht
BW
BMI
% fat
LBM
SM
Girls
SBP
DBP
SBP
DBP
0.149
0.282**
0.325***
0.275**
0.289**
0.285**
0.157
7 0.100
0.056
0.103
0.077
0.095
0.087
7 0.017
0.127
0.462***
0.521***
0.423***
0.163
0.560***
0.356***
0.216*
0.464***
0.434***
0.304**
0.110
0.476***
0.307**
Signi®cances: *P < 0.05; **P < 0.01; ***P < 0.001.
Ht ˆ height; BW ˆ body weight; BMI ˆ body mass index; %fat ˆ
percent body fat; LBM ˆ lean body mass; SM ˆ sexual maturation.
Table 4 Adjusted squared coef®cients (r2) of the regression of
anthropometric=body composition parameters and sexual maturation on
systolic (SBP) and diastolic (DBP) blood pressure. Age was included in all
statistical models, but its association with SBP=DBP did not reach
signi®cance.
Boys
SBP
Ht
BW
BMI
LBM
% fat
SM
0.047*
Ð
0.095** Ð
0.044*
Ð
0.054** Ð
0.040** 0.041*
Girls
DBP SM
Ð
Ð
Ð
Ð
Ð
Ð
Ð
Ð
Ð
Ð
SBP
SM
DBP
SM
0.201***
Ð
0.213*** Ð
0.210**
Ð
0.144*** Ð
0.124** 0.046*
Ð
0.063*
0.312***
Ð
0.212*** Ð
Ð
0.104**
Ð
0.061*
Signi®cances: *P < 0.05; **P < 0.01; ***P < 0.001.
Ht ˆ height; BW ˆ body weight; BMI ˆ body mass index; LBM ˆ lean
body mass; % fat ˆ percent body fat; SM ˆ sexual maturation.
maturation, whilst height, BW, BMI, lean body mass and
percent body fat were alternatively entered. Anthropometric variables were independently associated with SBP
in both sexes, explaining up to 31% of its variability in
girls, whilst they account for DBP variability in the female
subgroup only (Table 4). Percent body fat was associated
with SBP in boys only. When tested along with percent
body fat or BMI, an independent in¯uence of sexual
maturation on SBP and DBP was detected in the female
subgroup. In the male subgroup, sexual maturation was
associated with SBP only when percent body fat was
included in the analysis.
Discussion
The distribution of BW and height values in our population
shows a marked difference in BW between the children
from Carinaro and those studied by Tanner, at each age
group. Stature was also different, albeit to a smaller extent.
These data suggest a high prevalence of obesity in our
study group. This conclusion can also be supported comparing our results with those recently obtained in a population of 10 y old children living in Naples. Percentile values
of BMI in this group were markedly higher than in
populations of the same age and sex from other countries:
the prevalence of obesity, evaluated on the basis of different cut-off values, was always greater (Esposito-Del Puente
et al, 1996). In the village of Carinaro, we observed
percentile BMI values close to, or even higher than those
of Neapolitan children.
Several studies in adults (Stamler et al, 1978; Kannel et
al, 1967; Tyroler et al, 1975) as well as in adolescents
(Lauer et al, 1991; Horswill & Zipf, 1991) have shown a
close relationship between BW and BP levels. In a previous
observation in a suburban community of a geographical
area in the surroundings of Naples (Ferrara et al, 1989),
some of us have reported that BP increases concomitantly
with BW, values in higher BMI quintiles being signi®cantly
different from those of the lowest one. However, at that
time no data were collected on body composition and
sexual maturation stage: the lack of this information has
not allowed a multivariate analysis on the independent
in¯uence of BW on BP values.
In addition to BMI, simple indicators of percent body
fat, like triceps skinfold thickness, have been found useful
in children (Cronk & Roche, 1982). Moreover, also body
fat distribution (that is, waist-to-hip ratio), a better predictor
of cardiovascular mortality than BMI in middle age (Larsson et al, 1992), might help understand BP variability in
childhood. We did not ®nd any correlation between W=H
and BP, whilst our data con®rm the already known relationship between BW=BMI and BP values (Ferrara et al, 1989;
Lauer et al, 1991; Horswill & Zipf, 1991; Hofman &
Valkenburg, 1983; Falkner et al, 1981).
We have also investigated whether other anthropometric
factors, body composition and sexual maturation are related
to SBP and=or DBP. Gender appeared to in¯uence SBP,
which was signi®cantly higher in male than female students, independently of pubertal state. No sex-related
difference was detected in DBP values. The pubertal
subgroup of female students had signi®cantly higher BMI
and BP than the prepubertal subset, while pubertal boys had
less percent body fat than prepubertal ones. We found
height, BW and lean body mass to be strongly related to
SBP in both boys and girls, and to DBP in girls only. The
association of percent body fat with BP, on the other hand,
was weak and con®ned to SBP solely among boys. This
®nding is in agreement with previous studies (Vartiainen et
al, 1986; Stallones et al, 1982) indicating that fatness and
anatomical distribution of subcutaneous fat are not signi®cantly associated with BP during childhood.
The independent role of sexual maturation in determining BP values is still controversial (Vartiainen et al, 1986;
Daniels et al, 1996; Heald et al, 1963; Londe et al, 1975).
In this present study it was signi®cantly correlated to SBP
and DBP in girls when the Spearman correlation analysis
was performed; an independent role on BP variability was,
however, detected only when BMI or percent body fat were
considered, whilst it completely disappeared when BW,
height and lean body mass were tested in the regression
equation. This ®nding is only in part consistent with a
recent paper showing that the effect of sexual maturation on
BP operates through height and body fat (Daniels et al,
1996). Our data suggest, indeed, that sexual maturation
exerts its effect on BP mainly by acting on body size, whilst
percent body fat does not seem to have a very strong effect
on BP levels.
Conclusions
This study con®rms previous observations performed in
Southern Italy indicating that adiposity in the children of
this region is higher than in those of other countries. Body
size appears to be the most powerful determinant of BP
variability, whilst the in¯uence of sexual maturation seems
Body size=sexual maturation and blood pressure
G Leccia et al
to be largely mediated by its effects on anthropometric
parameters.
Acknowledgements ÐThe authors are grateful to Mrs. Rosanna Scala for
her linguistic revision, and to the dean and the teachers of the School `G
Petrarca'-Carauaco for their generous help in data collection.
References
Cronk CE & Roche AF (1982): Race and sex-speci®c reference data for
triceps and subscapular skinfolds and weight-stature. Am. J. Clin. Nutr.
35, 347 ± 354.
Daniels SR, Obarzanek E, Barton BA, Kimm SYS, Similo SL & Morrison
JA (1996): Sexual maturation and racial differences in blood pressure in
girls: the national heart, lung, and blood institute growth and health
study. J. Pediatr. 129, 208 ± 213.
Deurenberg P, Weststrate JA & Seidell JC (1991): Body mass index as a
measure of body fatness: age- and sex-speci®c prediction formulas. Br.
J. Nutr. 65, 105 ± 114.
Esposito-Del Puente A, Contaldo F, De Filippo E, Scal® L, Di Maio S,
Franzese A, Valerio G & Rubino A (1996): High prevalence of overweight in a children population living in Naples (Italy). Int. J. Obes. 20,
283 ± 286.
Falkner B, Kushner H, Onesti G & Angelakos ET (1981): Cardiovascular
characteristics in adolescents who develop essential hypertension.
Hypertension 3, 521 ± 527.
Ferrannini E, Buzzigoli G, Bonadonna R, Giorico MA, Oleggini
M, Graziadei L, Pedrinelli R, Brandi L & Bevilacqua S (1987):
Insulin resistance in essential hypertension. N. Engl. J. Med. 317,
350 ± 357.
Ferrara LA, Soro S, Mainenti G, Mancini M, Pisanti N, Borrelli R,
Moscato T & Mancini M (1989): Body weight and cardiovascular
response to sympathetic stimulation in childhood. Int. J. Obes. 13,
271 ± 277.
Heald FP, Daugela M & Brunschyler P (1963): Physiology of adolescence.
N. Engl. J. Med. 268, 192 ± 198.
Hofman A & Valkenburg HA (1983): Determinants of change in blood
pressure during childhood. Am. J. Epidemiol. 117, 735 ± 743.
Horswill CA & Zipf WB (1991): Elevated blood pressure in obese
children: in¯uence of gender, age, weight and serum insulin levels.
Int. J. Obes. 15, 453 ± 459.
Julius S & Johnson EH (1985): Stress, autonomic hyperactivity and
essential hypertension: an enigma. J. Hypertens. (Suppl) 3, S11 ± S17.
Kannel WB, Brand N & Skinner JJ Jr (1967): The relation of adiposity to
blood pressure and development of hypertension: the Framingham
study. Ann. Intern. Med. 67, 48 ± 59.
Larsson B, Bengtsson C, Bjontorp P, Lapidus L, Sjostrom L, Svardsudd
K, Tibblin G, Wecel H, Welin L & Wilhelms L (1992): Is abdominal body fat distribution a major explanation for the sex difference in
the incidence of myocardial infarction? Am. J. Epidemiol. 135, 266 ±
273.
Lauer RM, Burns TL, Clarke WR & Mahoney LT (1991): Childhood
predictors of future blood pressure. Hypertension 18, Suppl. I, I74 ± I81.
Locard E, Mamelle N, Billette A, Miginiac M, Munoz F & Rey S (1992):
Risk factors of obesity in a ®ve year old population. Parental vs
environmental factors. Int. J. Obes. 16, 721 ± 729.
Londe S, Johanson A, Kronemer NS & Goldring D (1975): Blood pressure
and puberty. Pediatrics 87, 869 ± 900.
Maffeis C, Schutz Y, Piccoli R, Gon®antini E & Pinelli L (1993):
Prevalence of obesity in north-east Italy. Int. J. Obes. 17, 287 ± 294.
Nie NH, Hull CH, Jenkins JG, Steinbrenner K & Bent DH (1975):
Statistical Package for Social Sciences, 2nd edn. New York:
McGraw-Hill.
Philipp TH, Distler A & Cordes U (1978): Sympathetic nervous system
and blood pressure control in essential hypertension. Lancet ii,
959 ± 963.
Second task force on blood pressure control in children (1987): Report of
the second task force on blood pressure control in children Ð 1987.
Pediatrics 79, 1 ± 25.
Stallones L, Mueller WH & Christensen BL (1982): Blood pressure,
fatness, and fat patterning among USA adolescents from two ethnic
groups. Hypertension 4, 483 ± 486.
Stamler R, Stamler J, Reidlinger WF, Algera G & Roberts RH (1978):
Weight and blood pressure: ®ndings in the hypertension screening of 1
million Americans. JAMA 240, 1607 ± 1610.
Tanner JM & Whitehouse RH (1976): Clinical longitudinal standards for
height, weight, height velocity, weight velocity and stages of puberty.
Archiv. Dis. ease Childhood 51, 170 ± 179.
Tyroler HA, Heyden S & Hames CG (1975): Weight and hypertension:
Evans Country studies of blacks and white. In Epidemiology and
Control of Hypertension, ed. O Paul, pp 177 ± 201. New York: Stratton
International.
Vartiainen E, Tuomilehto J & Nissinen A (1986): Blood pressure in
puberty. Acta. Paediatr. Scand. 75, 626 ± 631.
337