Improving the Generalizability and Risk Interpretation of Adolescent Hypertension Research: A Commentary on Loo et al.

Dear Editor,

We have read with interest the article ‘’Blood Pressure and Hypertension in Adolescents and Young Adults: Results From a Nationwide Screening Program ‘’by Loo et al. [1]. The authors' investigation into the prevalence of hypertension among Asian adolescents and young adults in Singapore is a remarkable contribution to the existing literature. A noteworthy advancement which offers insights that can play a pivotal role in future studies and public health initiatives. However, several methodological and contextual considerations warrant discussion to strengthen the study's interpretation and applicability.

As the study focuses solely on a Singaporean male population, its findings, particularly regarding risk factors such as diet and environmental exposures, may reflect region-specific trends. Previous studies, such as that by Meher et al., emphasize the significant impact of dietary habits, salt intake, and alcohol consumption, and these factors are not addressed in the current study [2]. Multicenter data collection would have enhanced the generalizability. The exclusion of females further limits generalizability, as blood pressure patterns are known to differ by sex. Including both genders would have yielded more representative and inclusive findings [3].

This study did not identify smoking as a significant factor in hypertension, which further contradicts the existing evidence, which suggests that smoking can increase the risk up to two to three folds [4]. Although the author's explanation regarding limited smoking exposure due to age is understandable, interpretation of the findings should be made with caution as it might mislead. Future studies should focus on the potential long-term effects of smoking initiation at adolescence. Additionally, the study did not evaluate secondary causes (such as renal or endocrine conditions) relevant in the younger populations [5]. These considerations would have provided a more comprehensive understanding of hypertension in this population and informed more effective prevention and treatment strategies.

Although the cross-sectional design provides a valuable snapshot in time, it does not evaluate the progression of blood pressure overtime. This limits further understanding of how early hypertension might later on progress into cardiovascular disease. Longitudinal follow-up is essential to understand whether early hypertension leads to adverse cardiovascular outcomes. Chen and Wang demonstrated that childhood blood pressure tracks into adulthood, underscoring the importance of longitudinal studies [6]. Socioeconomic status and environmental factors, which significantly influence adolescent blood pressure, were not considered, introducing potential residual confounding. These factors are known to influence adolescent blood pressure and should be prioritized in future analyses [7]. Addressing these limitations could significantly strengthen the study's clinical applicability and global relevance.

Conceptualization: Aisha Fatima and Muhammad Hassan Saeed. Literature review: Aisha Fatima, Mubashira Noor, and Syeda Eraj Zehra Rizvi. Writing-original draft: Mubashira Noor and Syeda Eraj Zehra Rizvi. Review and editing: Aisha Fatima and Muhammad Hassan Saeed. Supervision and correspondence: Muhammad Hassan Saeed.

The authors declare no conflicts of interest.

All authors have approved the final version of this letter.