Iranian Journal of Public Health 2017. 46(3):368-379.

Blood Pressure Nomograms for Children and Adolescents by Age and Body Mass Index in Tehran, Iran
Neamatollah ATAEI, Masoud BAIKPOUR, Mostafa HOSSEINI, Mahmoud YOUSEFIFARD, Mohammad FAYAZ, Fatemeh ATAEI, Arash ABBASI


Background: Normal standard references of blood pressure (BP) for children and adolescents should be constructed according to anthropometric indices. Therefore, we aimed to produce BP reference percentiles by body mass index (BMI).

Methods: Data on demographic characteristics, anthropometric indices and BP values of 16246 3-18-year-old children and adolescents from 3 cross-sectional studies conducted in Tehran were included. To justify the need for BMI adjustment, quantile regression model was applied for different percentiles of systolic and diastolic BPs with age, sex, and the corresponding BMI percentiles. Then, Age- and sex-specific BP nomograms were constructed according to BMI.

Results: All regression coefficients for BMI percentiles were significant in quantile regression of BPs, confirming the necessity for BMI-adjusted nomograms of BP. The BP percentiles for each gender by age and BMI are presented. All the BP percentiles rose steadily in all BMI percentiles with minor discrepancies between the two genders. As observed, the prevalence of hypertension is estimated to be lower among the lean subjects and higher among overweighs when the BMI-adjusted BP curves are considered.

Conclusion: The reference database constructed in this survey is the first Iranian BP reference by age and BMI in children and adolescents, from it concluded that BMI-adjusted BP curves depict a more precise picture of the hypertension prevalence and present a more reliable classification standard for hypertension.




Blood pressure; Nomograms; References; Body mass index

Full Text:



Lawes CM, Hoorn SV, Rodgers A (2008). Global burden of blood-pressure-related disease, 2001. Lancet, 371 (9623): 1513-8.

Somu S, Sundaram B, Kamalanathan A (2003). Early detection of hypertension in general practice. Arch Dis Child, 88 (4): 302.

Raitakari OT, Juonala M, Kähönen M, Taittonen L, Laitinen T, Mäki-Torkko N, et al. (2003). Cardiovascular risk factors in childhood and carotid artery intima-media thickness in adulthood: the Cardiovascular Risk in Young Finns Study. JAMA, 290 (17): 2277-83.

Bao W, Threefoot SA, Srinivasan SR, Berenson GS (1995). Essential hypertension predicted by tracking of elevated blood pressure from childhood to adulthood: the Bogalusa Heart Study. Am J Hypertens, 8 (7): 657-65.

Chen X, Wang Y (2008). Tracking of blood pressure from childhood to adulthood a systematic review and meta–regression analysis. Circulation, 117 (25): 3171-80.

Dekkers JC, Snieder H, van den Oord EJ, Treiber FA (2002). Moderators of blood pressure development from childhood to adulthood: a 10-year longitudinal study. J Pediatr, 141 (6): 770-9.

Al Salloum AA, El Mouzan MI, Al Herbish AS, Al Omar AA, Qurashi MM (2009). Blood pressure standards for Saudi children and adolescents. Ann Saudi Med, 29 (3): 173-8.

Jackson LV, Thalange NK, Cole TJ (2007). Blood pressure centiles for Great Britain. Arch Dis Child, 92 (4): 298-303.

Jafar TH, Islam M, Poulter N, Hatcher J, Schmid CH, Levey AS, et al. (2005). Children in South Asia Have Higher Body Mass–Adjusted Blood Pressure Levels Than White Children in the United States A Comparative Study. Circulation, 111 (10): 1291-7.

Tümer N, Yalcinkaya F, Ince E, Ekim M, Köse K, Cakar N, et al. (1999). Blood pressure nomograms for children and adolescents in Turkey. Pediatr Nephrol, 13 (5): 438-43.

Goonasekera C, Dillon M (2000). Measurement and interpretation of blood pressure. Arch Dis Child, 82: 261-5.

Arafat M, Mattoo TK (1999). Measurement of blood pressure in children: recommendations and perceptions on cuff selection. Pediatrics, 104 (3): e30.

Ataei N, Aghamohammadi A, Yousefi E, Hosseini M, Nourijelyani K, Tayebi M, et al. (2004). Blood pressure nomograms for school children in Iran. Pediatr Nephrol, 19 (2): 164-8.

Hosseini M, Baikpour M, Yousefifard M, Fayaz M, Koohpayehzadeh J, Ghelichkhani P, et al. (2015). Blood pressure percentiles by age and body mass index for adults. Excli J, 14: 465-77.

Horan M (1987). Report of the second Task Force on Blood Pressure Control in Children―1987. Pediatrics, 79 (1): 1-25.

National High Blood Pressure Education Program (2004). The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics, 114 (2 Suppl 4th Report): 555–76.

Report of the national high blood pressure education program working group on high blood pressure in pregnancy (2000). Report of the national high blood pressure education program working group on high blood pressure in pregnancy. Am J Obstet Gynecol, 183 (1): S1-S22.

Mi J, Wang T-y, Meng L-h, Zhu G-j, Han S-m, Zhong Y, et al. (2010). Development of blood pressure reference standards for Chinese children. Chin J Evid Based Pediatr, 5 (1): 4-14.

Neuhauser HK, Thamm M, Ellert U, Hense HW, Rosario AS (2011). Blood pressure percentiles by age and height from nonoverweight children and adolescents in Germany. Pediatrics, 127(4):e978-88.

Ashrafi M, Abdollahi M, Ahranjani B, Shabanian R (2005). Blood pressure distribution among healthy schoolchildren aged 6-13 years in Tehran. East Mediterr Health J, 11 (5-6): 968-76.

Ayatollahi S, Vakili M, Behboodian J, Zare N (2010). Reference Values for Blood Pressure of Healthy Schoolchildren in Shiraz (Southern Iran) using Quantile Regression. Iran Cardiovasc Res J, 4 (2): 55-65.

Kelishadi R, Ardalan G, Gheiratmand R, Majdzadeh R, Delavari A, Heshmat R, et al. (2006). Blood pressure and its influencing factors in a national representative sample of Iranian children and adolescents: the CASPIAN Study. Eur J Cardiovasc Prev Rehabil, 13 (6): 956-63.

Ataei N, Hosseini M, Fayaz M, Navidi I, Taghiloo A, Kalantari K, et al. (2016). Blood pressure percentiles by age and height for children and adolescents in Tehran, Iran. J Hum Hypertens, 30(4):268-77.

Hu G, Barengo NC, Tuomilehto J, Lakka TA, Nissinen A, Jousilahti P (2004). Relationship of physical activity and body mass index to the risk of hypertension: a prospective study in Finland. Hypertension, 43 (1): 25-30.

Brown CD, Higgins M, Donato KA, Rohde FC, Garrison R, Obarzanek E, et al. (2000). Body mass index and the prevalence of hypertension and dyslipidemia. Obes Res, 8 (9): 605-19.

Stamler R, Stamler J, Riedlinger WF, Algera G, Roberts RH (1978). Weight and blood pressure. findings in hypertension screening of 1 million Americans. JAMA, 240 (15): 1607-10.

Hosseini M, Carpenter R, Mohammad K (1998). Growth charts for Iran. Ann Hum Biol, 25 (3): 237-47.

Hosseini M, Navidi I, Hesamifard B, Yousefifard M, Jafari N, Ranji Poorchaloo S, et al. (2013). Weight, Height and Body Mass Index Nomograms; Early Adiposity Rebound in a Sample of Children in Tehran, Iran. Int J Prev Med, 4 (12): 1414-20.

Ataei N, Aghamohammadi A, Ziaee V, Hosseini M, Dehsara F, Rezanejad A (2007). Prevalence of hypertension in junior and senior high school children in Iran. Iran J Pediatr, 17 (Suppl 2): 237-42.

Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal KM, Guo SS, Wei R, et al. (2000). CDC growth charts: United States. Adv Data, (314): 1-27.

Cole TJ, Green PJ (1992). Smoothing reference centile curves: the LMS method and penalized likelihood. Stat Med, 11 (10): 1305-19.

Stanojevic S, Wade A, Stocks J, Hankinson J, Coates AL, Pan H, et al. (2008). Reference ranges for spirometry across all ages: a new approach. Am J Respir Crit Care Med, 177 (3): 253-260.

Cole T, Stanojevic S, Stocks J, Coates A, Hankinson J, Wade A (2009). Age‐and size‐related reference ranges: A case study of spirometry through childhood and adulthood. Stat Med, 28 (5): 880-98.

Rigby R, Stasinopoulos D (2005). Generalized additive models for location, scale and shape. Appli Statist, 54 (3): 507-54.

Muntner P, He J, Cutler JA, Wildman RP, Whelton PK (2004). Trends in blood pressure among children and adolescents. JAMA, 291 (17): 2107-13.

National Heart L, Institute B (1996). Update on the 1987 Task Force Report on High Blood Pressure in Children and Adlescents: A Work Group Report from the National High Blood Pressure Education Program. Pediatrics, 98: 649-57.

Rosner B, Prineas RJ, Loggie JM, Daniels SR (1993). Blood pressure nomograms for children and adolescents, by height, sex, and age, in the United States. J Pediatr, 123 (6): 871-86.

Neuhauser HK, Thamm M, Ellert U, Hense HW, Rosario AS (2011). Blood pressure percentiles by age and height from nonoverweight children and adolescents in Germany. Pediatrics, 127 (4): e978-e88.

Kamtsiuris P, Lange M, Schaffrath RA (2007). [The German Health Interview and Examination Survey for Children and Adolescents (KiGGS): sample design, response and nonresponse analysis]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz, 50 (5-6): 547-56.

Alsanjari O, de Lusignan S, van Vlymen J, Gallagher H, Millett C, Harris K, et al. (2012). Trends and transient change in end‐digit preference in blood pressure recording: studies of sequential and longitudinal collected primary care data. Int J Clin Pract, 66 (1): 37-43.

Wen SW, Kramer MS, Hoey J, Hanley JA, Usher RH (1993). Terminal digit preference, random error, and bias in routine clinical measurement of blood pressure. J Clin Epidemiol, 46 (10): 1187-93.


  • There are currently no refbacks.

Creative Commons Attribution-NonCommercial 3.0

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly.