ABSTRACT
Background
Nuts and algae have been shown to improve BP levels, but their effectiveness is controversial.
Aims
This study aims to illustrate the effect of dietary pattern with nuts and algae-less on BP levels in children and adolescents from a cross-sectional study.
Methods
A total of 5645 children from the Chongqing Children’s Health Cohort, aged 9.34 ± 1.74 years with 52.05% males, were analyzed. Stratified analysis was conducted to explore the differences between the two dietary patterns in urban or rural areas, as well as the differences in different gender. Logistic regression was used to analyze the influence factors of increased BP. And a GLM was used to analyze the influence of the two dietary patterns on systolic blood pressure (SBP, mmHg), diastolic blood pressure (DBP, mmHg), and mean arterial pressure (MAP, mmHg).
Results
Children with nuts and algae-less dietary patterns had higher SBP (104.68 ± 10.31 vs 103.81 ± 9.74, P = .006), DBP (64.27 ± 7.53 vs 63.55 ± 7.52, P = .002), and MAP (77.74 ± 7.75 vs 76.97 ± 7.52, P = .001) compared with those children with a balanced diet. After adjusting for covariates, the nuts and algae-less diet was a risk factor for hypertension in children when compared with the balanced diet(OR(95%CI):1.455(1.097,1.930), P = .009). The nuts and algae-less diet has a significant influence on SBP (104.68 ± 10.31 mmHg vs.103.81 ± 9.74 mmHg, P = .006). Stratified analysis by sex showed that nuts and algae-less dietary patterns had a more significant impact on females than males.
Conclusion
Nuts and algae-less dietary pattern correlated with increased BP levels in children, and a greater impact on SBP levels was found in females, suggesting that a balanced diet with appropriate nuts and algae should be proposed for children in China.
Introduction
Hypertension has become an important global health problem (Citation1). Elevated BP often appears in children and adolescents and is associated with an increased risk of cardiovascular disease (CVD) in adulthood (Citation2). According to the American Academy of Pediatrics (AAP) guidelines, there is an estimated prevalence of hypertension in children of 2–4% (Citation3). And the prevalence of hypertension in children had increased in recent years (Citation4). In addition, hypertension in children and adolescents may contribute to carotid intima-media thickness (Citation5), left ventricular hypertrophy (Citation6), and fibrous plaque formation (Citation7).
Recent studies have illustrated that diet has beneficial effects on CVD (Citation8). However, some studies had only shown the effects of single or several simple component diets on BP, without considering the synergistic effects among different types of foods (Citation9). Therefore, a classification of dietary patterns based on dietary habits would better explain the complexity of the human diet and evaluate more precisely the relationships between diet and BP (Citation10). Until recently, previous studies had revealed the impact of different dietary patterns on BP in both adults and children (Citation11). Among all dietary patterns, the representative Mediterranean-style diet (MDS) (Citation12) and the Dietary Approaches to Stop Hypertension Diet (DASH) (Citation13) have been explored for their effects on CVD. Other cohort studies (Citation14) have indicated the preventive effect of the MDS diet on BP and CVD in adults and children. The DASH diet trial has also shown conclusive evidence of beneficial effects on BP and other CVD risk factors (Citation9). For children, Abdollah Hojhabrimanesh et al. found that Western dietary patterns, which were rich in soft drinks, sweets and desserts, salt, mayonnaise, tea and coffee, high-salt snacks, high-fat dairy products, French fries, and red or processed meats, were associated with higher BP in Iranian adolescents (Citation15). The Framingham offspring study (Citation16) identified proteomic and metabolomic correlated with two dietary patterns, which may associate diet with cardiometabolic health and risk of hypertension. Nuts are enriched with unsaturated fatty acids, vegetable proteins, fiber, minerals, vitamins, and phytochemicals, which have been demonstrated to decrease BP (Citation17). Several studies have demonstrated that nut consumption was associated with a lower risk of developing hypertension, and CVD (Citation18). Our previous studies have also shown that the right dose of nuts can improve BP levels (Citation19). Similarly, algae contained a great source of compounds having multiple effects, which included the protection of the cardiovascular system. Torres-Duran et al (Citation20) reported that Spirulina has an anti-hypertensive effect in humans. In addition, an experimental report revealed that phycocyanins have a protective effect on hypertension or metabolic syndrome (Citation21).
However, most of the previous prospective studies only focus on the classification of dietary patterns on CVD, which was relatively simple and didn’t take into account geographic factors. And the subjects of the most studies were adults, fewer studies have been conducted on children. Therefore, to fill these knowledge gaps, this study investigated the effect of dietary patterns on hypertension in children in the urban-rural areas of Chongqing. In this study, the nuts and algae-less dietary pattern was compared with the balanced diet. In order to control confounders, the high-energy and low-energy dietary patterns were excluded from the analysis. The hypothesis of this study was that nuts and algae-less dietary patterns could influence BP levels in children. The aim of this study was to illustrate the effectiveness of nuts and algae-less dietary patterns on BP in children by comparing the nuts and algae-less dietary patterns with a balanced diet.
Methods
Participants
The subjects were from the Chongqing Children’s Health Cohort (CCHC). A two-stage stratified cluster sampling was used to recruit subjects, and the recruitment flow was described in our previous publications (Citation22). Briefly, the inclusion criteria were as follows: (1) children were 6–12 years old; (2) living in the chosen areas for >6 months; (3) without a serious disease (such as congenital heart disease, kidney disease, or cancer, et. al.); (4) children and their parents or guardians signed informed consents to participate in the cohort study. After excluding subjects, attributing to refusing to sign the informed consent or samples with missing information, 10597 participants from one urban area and one rural area have remained. According to Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC) and entropy, the most representative dietary pattern of children in Chongqing was determined. The proportion of participants was used as the weight, and then different food types of each type of dietary pattern were divided into quartiles respectively. Thus, it can be seen that the lowest quartile of nut intake was more than 50%. Therefore, the first type of dietary pattern was the diet pattern with fewer nuts, and the other three dietary patterns were named in turn. The 10,597 participants were clustered and analyzed according to their dietary habits, resulting in four dietary patterns: the nuts and algae-less dietary pattern, the high-energy dietary pattern, the low energy dietary pattern, and the balanced dietary pattern. This study focused on nuts and algae and BP levels, the effects of confounding factors such as energy would also have to be considered, so only two dietary patterns were included in the study, the nut and algae-less dietary pattern and the balanced dietary pattern, and a total of 5645 participants were included in the analysis, with 2407 participants had glycolipids indicators (in Supplement ). This study was carried out under the agreement of the Institutional Review Board of Children’s Hospital of Chongqing Medical University (No. 2013–86).
Figure 1. The effect of nuts and algae-less diet on SBP/DBP using logistic regression model.
Physical examination
The demographic characteristics and physical measurements were surveyed. Well-trained pediatric nurses and doctors joined in the physical examination (height, weight, waist circumference, and BP), and a detailed description of the protocol has been published in our previous papers (Citation22). BP was measured using an arm-type electronic sphygmomanometer (OMRON, HEM7051), and an appropriately sized BP cuff, was placed on the right arm of the children, in a seated position, which the specific operation process was introduced in our previous published papers (Citation22). In consideration of the differences in the growth and development characteristics of children and adolescents, this study used the BP diagnosis standard developed by Fan Hui and Mi Jie et al. 2017 (Citation23), which was suitable for growth and development characteristics of Chinese children and adolescents. Then, the average SBP and DBP values were calculated using the average mean of three times BP levels on one occasion.
Demographic characteristics
Demographic variables were collected using a self-administered structured questionnaire that investigated perinatal variables including adolescent development, passive smoking, maternal obesity and birth weight, maternal education, and household income using a structured questionnaire. In addition, a quantitative dietary questionnaire, including frequency and dose of dietary intake, was used to collect dietary information, as described in a previous publication (Citation22).
Biochemical indexes
Between 7:30 and 10:30 am, venous blood was collected after 12 hours of fasting, and serum and plasma were separated from whole blood as described in our previous publications (Citation22). Serum samples were then stored in a refrigerator at −80°C for later biochemical measurements. And glucolipid metabolism indicators were examined by an automated biochemical analyzer (Mindray BS-800), which included serum fasting blood glucose (FBG), total cholesterol (TC), triglycerides (TGs), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C).
Dietary intake information
A semi-quantitative food frequency questionnaire was used to collect dietary intake information. A classification of foods into 15 categories was used, including cereals, vegetables, fruits, meat, poultry, fish and shellfish, eggs, milk and dairy products, legumes and soy products, nuts, algae, edible oils, preserved products, nutritional supplements, and beverages. On a household basis, the average daily intake of cooking oils was then estimated by collecting how often family members ate at home, and the total consumption of cooking oils over a period of time was estimated. The amount of food was investigated by interviewing parents of children regarding their intake and frequency during a period, and then the total amount of food was averaged into the daily intake. To ensure the validity of the survey, standardized utensils for holding food (bowls, plates, cups, spoons, etc.) were used to show the amount of food.
Statistical analysis methods
For continuous variables, T-tests were used to analyze the difference in the characteristics of participants between dietary patterns with fewer nuts and algae and dietary patterns with a balanced diet. In addition, χ2 has been used to analyze the difference of categorical data. Logistic regression models were constructed with hypertension, systolic-hypertension, and diastolic-hypertension as the dependent variable, and the independent variable was dietary patterns (dietary patterns with less-nuts and algae vs. dietary patterns with a balanced diet), and covariates were included from the model 1 to model 6 to calculate the effects of dietary patterns with less-nuts and algae on hypertension. And model 7 was a full model, which included all the significant covariates. Statistical results were taken as two-sided test results, and α < 0.05 was considered a statistically significant difference. The statistical software of SAS 9.4 was used.
Results
Demographic characteristics
The demographic characteristics were described in . There are 5,645 children with a mean age of 9.34 ± 1.74 years, among them, 2938 (52.05%) boys, were included in this study. Compared with a balanced dietary pattern, the proportion of males with nut and the algae-less dietary pattern was less (25.53% vs. 74.47%). And the average age was statistically significant between the two dietary pattern groups (P < .001). The height and weight of children in the nuts and algae-less dietary pattern group were higher than those in the balanced dietary pattern (P < .05). Moreover, the dietary pattern of nuts and algae-less in rural was more common than in urban (71.41% vs 28.59%), and the difference in dietary patterns between rural and urban was statistically significant (P < .001) (in ).
Table 1. The characteristics of participants in this study.
The effect of nut and algae-less dietary patterns on BP level
The effect of two dietary patterns on BP in children were shown in . Compared with the balanced dietary pattern, SBP (104.68 ± 10.31 mmHg vs. 103.81 ± 9.74 mmHg), DBP (64.27 ± 7.53 mmHg vs. 63.55 ± 7.52 mmHg), and MAP (77.74 ± 7.75 mmHg vs. 76.97 ± 7.52 mmHg) were higher in the group of nuts and algae-less dietary patterns, the differences were all statistically significant (P < .05). According to the diagnostic criteria from China (Citation23), the prevalence of systolic hypertension was higher among the nuts and algae intake groups (in ).
Table 2. The effect of two dietary patterns on blood pressure levels and hypertension.
Table 3. The effect of nuts and algae-less diet on BP levels in children using the GLM.
Table 4. The effect of nuts and algae-less diet on hypertension in children using the logistic regression model.
The effect of nut and algae-less dietary patterns on SBP, DBP, and MAP in children was analyzed using the GLM in . The nut and algae-less dietary patterns were positively associated with SBP (β: 0.872, P = .004), DBP (β: 0.726, P = .002), and MAP (β: 0.775, P < .001) in model 1. After adjusting age, sex, height, weight, income, HDL, and TG in model 7, the association between the nuts and algae-less intake and SBP(β:0.984 , P = .027) DBP (β: 1.246, P = .002), and MAP (β: 1.159, P = .002) were also significant.
The difference in the effect of nuts and algae dietary patterns between males and females was shown in Supplement and Supplement . The results of the study showed that after adjusted multi-variables, among males, the association between the nuts and algae-less dietary patterns and hemodynamic indexes (SBP, DBP, and MAP) was not statistically significant (in Supplement ). However, in females, these associations were significant, even after adjusting for age, height, weight, income, HDL, and triglycerides in model 7 (in Supplement ).
In addition, the effects of nut and algae-less dietary patterns on SBP, DBP, and MAP in urban-rural areas were described in Supplement and Supplement . After adjusting for covariates, the nuts and algae-less dietary pattern was statistically significantly associated with DBP in the urban region only in model 6 and model 7 (in Supplement ). For children living in a rural area, the nuts and algae-less dietary pattern was not statistically associated with SBP, DBP, and MAP (all P > .05) (in Supplement ).
The effect of the nuts and algae-less dietary pattern on hypertension in children
The impact of the nuts and algae-less dietary pattern on hypertension is shown in . Compared with the balanced dietary group, the Nuts and algae-less diet group were more likely to have a higher risk of hypertension (OR (95% CIs): 1.195 (1.014–1.408, P = .034)). After adjusting for covariates, in model 6 and in model 7, the nuts and algae-less dietary pattern was also significantly associated with a higher risk of hypertension prevalence (OR (95% CIs):1.512(1.155–1.978), P = .003; OR (95% CIs): 1.455 (1.097, 1.930), P = .009). As shown in , stratified analyses by area and sex were conducted to explore the relationship between two dietary patterns and hypertension. The nuts and algae-less dietary pattern was significantly associated with hypertension only in females (OR (95% CIs):1.816(1.213, 2.719); P = .004).
Figure 2. The effect of nuts and algae-less diet on hypertension using logistic regression model by urban-rural regions.
Figure 3. The effect of nuts and algae-less diet on hypertension using logistic regression model by sex.
In addition, the effect of nuts and algae-less dietary pattern on systolic/diastolic hypertension in children was shown in . Both in the crude and the multivariate-adjusted model, a similar trend in the relationship between the nuts and algae-less dietary pattern and systolic hypertension was observed, as the nuts and algae-less dietary pattern group had an increased risk of systolic hypertension (P < .05) (in ). However, diastolic hypertension was not significantly associated with nuts and algae-less dietary pattern in model 1(OR (CI 95%):1.052 (0.856, 1.293); P = .629). However, after adjusting for covariates, the nuts and algae-less dietary pattern was significantly associated with the risk of diastolic hypertension (OR (95% CIs):1.415 (1.001, 1.999); P = .049).
Discussion
In our study, we found that children with a dietary pattern containing less nuts and algae had higher BP levels and the correlation remained even after adjusted multi-covariates, compared with those children with a balanced diet. In addition, the relationship between nuts and algae intake and BP has a sex difference, as the effects on BP levels in females were significant, which was not identified in males.
Although the differences in SBP/DBP and the crude prevalence of the different types of hypertension between the two dietary pattern groups are minute, there are significant (P < .05). First, this study included a large sample size, and it could not be a considerable difference between the two dietary pattern groups, but it was significant. However, this minute difference in the natural population was significant and indicated that a nuts and algae-less diet had an effect on blood pressure. Second, blood pressure in children is influenced not only by diet, but also by other factors such as genetics, obesity, and environment. Therefore, the effects from diet, especially from a nuts and algae-less diet may be minute. Finally, the independent effect was illustrated, as several models were used to adjust multiple confound factors.
Similarly, the effect of a specific dietary pattern in males and females may have a different health effect. As the results of two dietary patterns in Korea (Citation24) showed that a rice-rich pattern in refined carbohydrates was positively associated with the risk of hypertension in Korean adults, mainly among females. Diets that are rich in whole grains and legumes were negatively associated with the risk of hypertension in Korean females (Citation25), and in all these studies, BP levels in females were shown to be more susceptible to dietary influences, which is consistent with our findings. There are several possible reasons for the different effects of the same dietary pattern on BP in males and females. First, studies have found that estrogen was a protective factor for BP which may explain the difference in prevalence between males and females (Citation26). CVD prevalence was more serious in males than in age-matched premenopausal females. However, among females, who were postmenopausal, the risk for BP and CVD events increased significantly (Citation27). The increase in BP among postmenopausal females might be due to dramatic changes of hormone levels between males and females. It has been established that estrogen influences the vascular system by inducing vasodilatation, increasing nitric oxide (NO) bioavailability, inhibiting vascular remodeling processes and vascular response to injury, and modulating the renin-angiotensin-aldosterone system (RAAS) and the sympathetic system (Citation28), and also increased angiotensin II (Ang II) level was associated with increased BP (Citation29). In contrast, an animal experiment (Citation30) showed that rats fed almonds, cashews, and peanuts groups had estrogenic activity, which measured estrogenic activity in vivo by feeding different types of food to ovariectomized Wistar rats for 10 days. This might explain the different effects of different dietary pattern on BP levels by gender. Second, it has also been noted (Citation31) that this sex difference phenomenon was related to social and family environment support. Social support has also been identified as a protective factor for various health outcomes, including hypertension and cardiovascular disease (Citation32). Females are more likely to manifest a more pronounced trust in healthy nutrition, and greater engagement in controlling body weight (Citation33). More research is needed in the future to account for this sex difference.
Limited conclusions about the correlation of algae with BP in humans were reported. A previous study found that the preventive effect of algae against hypertension has been associated with their rich dietary fiber and mineral content (Citation34). A study illustrated that Clostridium algae had several biological activities, and previous studies of Clostridium on cardiovascular system diseases have focused on polypoidal anti-inflammatory effects (Citation35). In addition, a systematic review of the literature on the production, composition, and activity of ACEi peptides derived from algal proteins revealed that ACEi peptides derived from macroalgae and microalgae have potential anti-hypertensive effects (Citation36). Most of the evidence about the correlation between algae and hypertension were from animals (Citation37), and fewer studies were from a human. Research demonstrated that low molecular weight potassium alginate (L-PA) can reduce BP levels in spontaneously hypertensive rats (Citation38). It has been demonstrated that the polysaccharide L-PA extracted from the edible brown alga Laminaria japonica grown in Qingdao seawater, China, prevented the development of DOCA salt-induced hypertension in rats in a dose-dependent manner (Citation39). Therefore, this study provided new evidence of the negative relationship between algae and BP.
Recently, there were several studies confirmed that the reduction of nuts consumed was a risk factor for BP levels (Citation40). First, the nutritional content of nuts varies by type. However, Nuts are well-known to be a nutrient-rich food, especially as a source of Ca, Cu, Te, Mg, and P, which may regulate BP. For instance, Ca through increasing intracellular Ca levels inhibit parathyroid hormone, and induces hypertension (Citation41); Mg could stimulate the vasodilator prostacyclin and nitrous oxide production, then blocks Ca channels and induces vasodilation (Citation42). Secondly, nuts have a regulatory effect on angiotensin-converting enzyme (ACE). The renin-angiotensin system (RAS) is an important humoral regulatory system (Citation43) that plays an important role in regulating BP and maintaining cardiovascular function in humans. RAS-mediated processes affecting BP are thought to cause vasoconstriction and increase BP via the classical ACE-AngII-AT1R pathway (Citation44). Cashew nuts and betel nut kernels (Citation45) contain ACE inhibitory peptides, which leads to a decrease in angiotensin II, thus resulting in a decrease in BP level.
Thirdly, nuts contain unsaturated fatty acids, and some evidence suggested that polyunsaturated fatty acids (PUFA), such as ω-3 PUFA, have a favorable prognosis in patients with CVD (Citation46). ω-3 PUFA affects ion channels and receptors by altering the structure and function of cell surface microdomains, reducing oxidative stress, and regulating the function of cell membranes (Citation47), and finally, it affects BP. Similarly, cross-sectional studies in which dietary intake was assessed by food records (Citation48) showed that PUFA intake was negatively associated with BP level. A prospective cohort study of more than 80,000 nurse practitioners showed a protective effect of PUFA on BP (Citation49). As well, PUFA was negatively associated with SBP in a 6-year follow-up study of atherosclerosis risk from the community (Citation50). Thus, one of the mechanisms by which nuts modulate BP may be through PUFA affecting BP levels. Finally, the intake of nuts may affect inflammatory factors (Citation51). Gulati et al. reported a significant reduction in C-reactive protein (CRP) after pistachio consumption in adults with metabolic syndrome (Citation52). Animal experiments also showed that a diet of mixed nuts (almonds, Brazil nuts, cashews, macadamia nuts, peanuts, walnuts, pistachios, and walnuts) for 8 weeks reduced the levels of CRP and HMGB1 in rats (Citation53). CRP and HMGB1 are highly sensitive biomarkers of systemic inflammation and an important indicator of cardiovascular risk (Citation54). These suggest that nuts may influence BP by affecting inflammatory factors.
Strengths
This study has several strengths. First, this study is the first study to consider the effect of dietary patterns with nuts and algae-less together with other foods on BP levels in children, which can provide a reference for future dietary formulation for children. Second, this study included a large sample size of urban-rural children from communities, and the results are representative. Third, multi-variables were adjusted in the analyses, which may control the confounders, and the results were reliable and credible. Finally, the stratified analysis revealed that the BP levels of females were influenced by the nuts and algae-less dietary patterns, which can provide suggestions for future dietary guidance.
Limitations
This study has two limitations. Firstly, the recall bias existed, as the dietary questionnaire was filled by parents and children. However, we reviewed 10% of these questionnaires by telephone participants about the dietary to guarantee the authenticity of the questionnaire. Secondly, this was a cross-sectional study, and calculated the amount of food eaten by collecting the frequency of eating habits in the past year, which cannot accurately illustrate the long-term etiological relevance between the nuts and algae-less intake and BP level. However, the correlation between dietary intake and blood pressure was confirmed in a retrospective study; and several dietary-related articles were published, using the data from this cohort (Citation19), which might indicate the reliable of the dietary data in this study. Moreover, this cohort explores the impact factors of children with hypertension, and the long-term effect of diet on blood pressure levels in children will be illustrated the results of our study could suggest a link between the them.
Conclusion
Our study found that the nuts and algae-less dietary pattern was a risk factor for BP levels in children and had a more significant effect on girls. These findings suggest that the amounts of nuts and algae intake was correlated with BP levels of children, which provides a favorable basis for the development of relevant dietary policies in the future and provides scientific recommendations for the prevention and control of hypertension in childhood.
Author Contributions
XH: Conceptualization, Methodology, Writing - Review & Editing; QJ and XL: Investigation, Supervision; YF, YL, and ZP: Validation, Resources; YL, YF and XY: Writing – Original Draft, Writing - Review & Editing. All of the authors critically reviewed and approved the final paper.
Supplemental Material
Download Zip (82.6 KB)Acknowledgments
The authors would like to acknowledge the laboratory support of the Ministry of Education Key Laboratory of Child Development and Disorders and all the staff members of the 6 elementary schools in the two regions.
Data Availability Statement
The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request (Email: [email protected]).
Disclosure statement
No financial or non-financial benefits have been received or will be received from any party related directly or indirectly to the subject of this article.
Supplementary material
Supplemental data for this article can be accessed online at https://doi.org/10.1080/10641963.2023.2180024
Additional information
Funding
References
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