Healthy lifestyle program for hypertensive adolescents with a Vitamin D deficiency

Introduction

Previous studies have shown that there was a direct correlation between blood serum level of vitamin D and blood pressure taking into account the sensitivity of the vitamin D receptor.1, 2, 3 This pointed to a most likely role of vitamin D deficiency in the development of hypertension among adolescents. Other studies4, 5 also reported that vitamin D deficiency from childbirth to early and late childhood was linked to a higher risk of an elevated systolic blood pressure during childhood.

The established global blood pressure reference values for children aged between six and 19 years are as follows: Prehypertension, systolic blood pressure range between 130 and 139 mmHg and diastolic blood pressure between 85 and 89 mmHg. Stage one hypertension, systolic blood pressure range between 140 and 159 mmHg and diastolic blood pressure between 90 and 99 mmHg. Stage two hypertension, systolic blood pressure range between 160 and 179 mm/Hg and diastolic blood pressure between 100 and 109 mm/Hg.6

Sometimes, diagnosing hypertension can be very difficult and early detection has been deemed very important especially in preventing the associated risk of heart disease.7 In more recent years, the medical field has noticed a rising incidence of paediatric hypertension with studies noting that more than 75 percent of teenagers remain undiagnosed. Studies also showed that the actual incidence of hypertension among teenagers was higher than the established rate of those as being diagnosed.8

Hypertension is a complex and multi-layered disease compounded by several risk factors such as diet and nutrition, stress and activity levels among others.9 Although about 90-95 percent of causes linked to high blood pressure remain unknown, certain groups of people have been identified as having an increased risk of developing hypertension.10 Other factors linked to hypertension include vitamin D deficiency which is an offshoot of being overweight and obese, academic stress, metabolic and hereditary factors, racial and ethnic predispositions, socio-economic status, cultural influences, growth rate and pubertal stage all of which made diagnosis a more daunting and demanding task.11

One of the more established factors associated with hypertension is a sedentary lifestyle defined as lacking or limited physical activity by a person. One example of a sedentary lifestyle consists of watching television or playing video games for long periods of time. Hypertension has been linked to a lack of exercise as well as lack of vitamin D in the umbilical cord blood during birth specifically lower than 11 ng/ml and lower than 25 ng/ml during the paediatric period of early childhood.12

Medical guidelines have established a pediatric as having a definite vitamin D deficiency when the amount of vitamin D in the blood is 25- D < 20 ng/ml, insufficiency as 21-29 ng/ml and sufficiency between 30-100 ng/ml.13 The same guidelines instructed that in order to avoid being vitamin D deficient, intakes of vitamin D for paediatric less than one year of age should be between 400–1,000 IU/d and 600–1,000 IU/d for paediatric from one to 18 years of age.14

Vitamin D consumption is very important during the paediatric period as it is needed in accretion and bone development as well as for calcium absorption during the adolescent period. Certain diseases such as type 1 diabetes mellitus, hypertension, multiple sclerosis and cancer can be prevented by maintaining sufficient levels of vitamin D.15 Apart from its effects on skeletal development such as promoting a normal bone growth and mineralisation during childhood, Vitamin D supplementation has also been known to prevent paediatric rickets. Adolescents who have sufficient exposure to sunlight and have a diet rich in foods like eggs, salmon and fortified milk products are considered to have achieved vitamin D supplementation from natural sources,16, 17

Adolescents should be introduced to a healthy lifestyle control program early in life in order to improve their knowledge and lifestyle practices with the end goal of disease prevention. A collaborative effort between parents, school and health authorities should be made to promote awareness regarding hypertension in young people and discuss its prevention and control.18 Our healthy lifestyle program prescribed lifestyle modification as well as weight control, exercise and a healthy diet in the improvement of blood pressure and overall health among adolescents.19 Nurses who were involved in the project detected hypertension through screening although they also helped in educating parents and children about the debilitating effects of hypertension in their lives. They also helped promote the practice of a healthy lifestyle by discussing the importance of vitamin D, good nutrition and exercise among others in an effort to avoid high blood pressure among adolescents.20

Significant of Research

Hypertension has been identified as one of the major causes of high mortality and morbidity worldwide as well as a prime factor leading to stroke and coronary heart disease. Recent studies conducted in several western countries have shown an increasing rate of hypertension among children from seven to 19 percent.21 A similar trend appeared among adolescents in Alexandria, Egypt where the prevalence rate of hypertension increased with age progression namely from a rate of 4.8 percent among adolescents aged 13-14 years to 15.7 percent among 17-year-olds.22 There is a global problem of vitamin D deficiency with sub-optimal levels of 25(OH)D being a common occurrence. A severe deficiency was also identified mostly in the Middle East. Low serum 25-OHD (< 20 ng/ml) was found in 11.5 percent of the total sample taken from 200 boys and girls aged nine to eleven years who were recruited from two primary schools in Egypt’s Giza governorate.23

Children who had low vitamin D from birth exhibited approximately 60 percent higher risk of systolic blood pressure at ages six-18 years while children who had continuous low levels of vitamin D through early childhood had a double risk of elevated systolic blood pressure at ages three-18 years.24, 25

The healthy lifestyle program proved to be quite effective in reducing blood pressure by focusing on lifestyle and dietary changes like reducing sodium consumption and increasing potassium intake as well as weight loss, stress reduction and regular exercise. All types of physical activity are considered advantageous towards maintaining a healthy blood pressure and should consist of a minimum of 150 minutes of moderate activity per week.16 One critical aspect in the effective prevention, treatment and control of hypertension is early detection and diagnosis26, 27 The main purpose of the healthy lifestyle program was to improve the subjects’ management of their condition by giving them training on how to properly measure blood pressure as well as impressed on them the importance of daily home-based monitoring in addition to improving their knowledge on various sources of vitamin D.

Materials and Methods

Ethical Consideration

All the measurements were conducted in private rooms in the hospital’s out-patient clinics. All data collected through the self-reported questionnaires were kept confidential. Respondents were given the option not to participate in the study or to withdraw from the measurements prior to the completion of the program.

Results

Figure 1: This illustrates that 72 percent of adolescents had a family history of hypertension at a near relative degree and 34 percent had a family history of obesity at a far relative degree while 38 percent of adolescents had no family history of diabetes mellitus.

Figure 1

Distribution of hypertensive adolescents with vitamin D deficiency related to family history of chronic disease

Program

This table illustrates the efficiency of the healthy lifestyle program as shown by the statistically significant difference and a clear improvement of the healthy lifestyle of adolescents after the program. The highest proportion after the program was in the appropriate diet as it limited the consumption of foods rich in sugar and sodium. The best healthy lifestyle in the vitamin D source category was natural sun exposure or ultraviolet B irradiation with a value of 96.3 percent. After the education program, some 89.3 percent of adolescents were on the opinion that physical activity should take place every 2-3 days per week for a duration of 30 minutes to one hour.

Figure 2

Comparison of total lifestyles between male and female hypertensive adolescents with vitamin D deficiency before and after the healthy lifestyle program

Figure 2: This illustrates that female adolescents had a higher improvement of 89 percent in their healthy lifestyles after undergoing the healthy lifestyle program compared to male adolescents who showed a slightly less score of 87 percent.

Table 2

Relationship between socio-demographic characteristics of hypertensive adolescent with vitamin D deficiency and their healthy lifestyle before and after the healthy lifestyle program

Variables		Healthy life style																							χ2	P
		Before program										After program
		Source of vit D		Proper diet				Physical activity				Source of vit D				Proper diet					Physical activity
		Enough	Not enough	Constantly		Occasionally		Active		Non active		Enough		Not enough		Constantly			Occasionally		Active		Non active
	F	%	F	%	F	%	F	%	F	%	F	%	F	%	F	%	F	%	F	%	F	%	F	%
Gender
Male (n=150)	30	20	120	80	35	23,3	115	76,7	65	43,3	85	56,7	125	83,3	5	1,7	123	82	27	18	141	94	9	6	7.03	0.02
Female (N=150)	20	13,3	130	86,7	55	36,7	95	63,3	23	15,3	127	84,7	135	90	15	10	144	96	6	4	122	81,3	28	18,7	8.05	<0.05
11-14	22	7,3	50	16,7	60	20	150	50	60	20	111	37	66	22	6	2	187	82	23	7,7	180	60	30	10	7.23	0.04
14-18	28	9,3	200	66,7	30	10	60	20	40	13,3	89	29,7	225	75	3	1	86	96	4	1,3	119	39,7	10	3,3	4.12	<0.01
Education
Primary	10	3,3	50	16,7	22	7,3	80	26,7	33	11	55	18,3	42	14	18	6	92	96	10	3,3	83	27,7	2	0,7	9.45	0.03
Preparatory	20	6,7	40	13,3	21	7	100	33,3	12	4	87	29	55	18,3	5	1,7	111	82	20	6,7	88	29,3	11	3,7	8.13	0.02
Secondary	20	6,7	60	20	25	8,3	52	17,3	55	18,3	58	19,3	76	25,3	4	1,3	72	96	5	1,7	109	36,3	4	1,3	3.56	<0.05
Economic status
Appropriate	17	5,7	180	60	10	3,3	236	78,7	33	11	96	32	186	62	11	3,7	240	96	6	2	102	34	27	9	9.23	<0.05
Non appropriate	33	11	70	23,3	21	7	33	11	44	14,7	127	42,3	100	33,3	3	1	44	82	7	2,3	167	55,7	4	1,4	3.76	0.23
House condition
Healthy	17	5,7	190	63,3	12	4	186	62	18	6	154	51,3	200	66,7	7	2,3	190	82	8	2,7	165	55	7	2,3	7.13	0.14
Unhealthy	33	11	60	20	33	11	70	23,3	52	17,3	76	25,3	88	29,3	5	1,7	90	96	3	1	108	36	20	6,7	3.12	<0.01

Table 3: The study showed that there was a statistically significant relationship between the adolescents’ healthy lifestyle and their socio-demographic characteristics such as their gender as females aged between 14-18 years old with secondary education and having appropriate economic status and healthy house conditions. After undergoing the healthy lifestyle program, the study also showed that among the male adolescent subjects, 94 percent were physically active, 60 percent were aged between 11-14 years and 55.7 percent had non-appropriate economic status.

Table 3

Distribution of blood pressure and 25-hydroxy vitamin D measurements ofadolescents (N= 300) before and after the healthy lifestyle program

Variable	Before-program												After two months from healthy lifestyle program												t	P
	Blood pressure								25-hydroxy vitamin D				Blood pressure								25-hydroxy vitamin D
	Systolic				Diastolic				Deficient		Insufficient		Systolic				Diastolic				Optimal		Insufficien
	Controlled		high		Controlled		high		F	%	F	%	Controlled		High		Controlled		High		F	%	F	%
	F	%	F	%	F	%	F	%					F	%	F	%	F	%	F	%
Male adolescents	70	46.7	80	53.3	60	40	90	60	77	51.3	73	48.7	140	93.3	10	6.7	135	90	15	10	145	96.7	5	3.3	3.12	<.05
Female adolescents	100	66.7	50	33.3	120	80	30	20	80	53.3	70	46.7	120	80	30	20	144	96	6	4	138	92	12	8	2.34	<.05

Table 3 The study showed that after having been through the two-month healthy lifestyle program, a high number of both female and male adolescents were able tostabilise their blood pressures as shown by their blood pressure readings. Similarly, most of the adolescents with 25-hydroxy vitamin D deficiency were able to achieve optimal vitamin D sufficiency from a previous state of being vitamin D deficient and insufficient after going through the healthy lifestyle program.

Figure 3

The difference of knowledge levels of hypertensive adolescents in relation to vitamin D before and after the healthy lifestyle program

Figure 3: The study revealed a statistically significant difference on the knowledge levels of adolescents after undergoing the healthy lifestyle program. The adolescents showed a good knowledge level of 88 percent for predisposing factors and 77 percent for screening tests of vitamin D.

Figure 4

Difference of knowledge levels of adolescents in relation to hypertension before and after the healthy lifestyle program

Figure 4: The study showed a statistically significant difference in the knowledge levels of adolescents pertaining to blood pressure after undergoing the healthy lifestyle program. The adolescents obtained a good knowledge level of 90 percent for signs and symptoms and 71 percent for avoidance of complications.

Figure 5

Difference of total knowledge levels between genders before and after the healthy lifestyle program

Figure 5: The study showed that female adolescents achieved a more satisfactory knowledge level of 95 percent after undergoing the healthy lifestyle program compared to male adolescents who scored a lower knowledge level of 90 percent.

Table 4: Distribution of adolescents’ practice in relation to blood pressure measurement before and after the healthy lifestyle program (N=300).

Table 4

Distribution of adolescents’ practice in relation to blood pressure measurement before and after the healthy lifestyle program (N=300).

Practice steps	Before program			After program			t
	Done well	In correct	Not done	Done well	In correct	Not done
	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)
- Prepare stethoscope	59(19.7)	65(21.7)	176(58.7)	300(100)	0	0	9.03	0.02
-An appropriately sized blood pressure cuff	40(13.3)	169(56.3)	91(30.3)	279(93)	21(7)	0	5.54	<0.05
-A blood pressure measurement instrument such as an aneroid or mercury column sphygmomanometer or an automated device with a manual inflate mode.	45(15)	87(29)	168(56)	300(100)	0	0	6.04	<0.05
- Five minutes to relax before the first reading.	2(0.6)	5(1.7)	293(97.7)	262(87.3)	23(7.7)	15(5)	7.03	<0.05
- Sit upright with their upper arm positioned so it is level with their heart	0	9(3)	291(97)	234(78)	66(22)	0	5.98	<0.05
-Remove excess clothing that might interfere with the BP cuff or constrict blood flow in the arm.	79(26.3)	88(29.3)	133(44.3)	198(66)	77(25.7)	25(8.3)	6.98	<0.05
-No talking during the reading.	78(26)	99(33)	123(41)	300(100)	0	0	5.45	<0.05
- Wrap the BP cuff snugly around the arm.	38(12.7)	96(32)	166(55.3)	293(97.7)	6(	1(	4.21	<0.05
-Palpate/locate the brachial artery and position the BP cuff so that the ARTERY marker points to the brachial artery.	0	1(0.3)	299(99.7)	245(81.7)	50(16.7)	5(1.7)	5.72	<0.05
- Place the bell of the stethoscope over the brachial artery at strongest pulse sounds.	4(1.3)	95(31.7)	201(67)	265(88.3)	22(7.3)	13(4.3)	5.34	<0.05
-Begin pumping the cuff bulb and inflated to 160 - 180 mmHg until no hear sounds through the stethoscope.	59(19.7)	37(12.3)	257(85.7)	255(85)	42(14)	3(1)	4.32	<0.05
- Slowly Deflate the BP cuff should fall at 2 - 3 mmHg per second, because faster may likely result in an inaccurate measurement.	40(13.3)	3(1)	296(98.7)	295(98.3)	1(0.3)	4(1.3)	5.21	<0.05
- Listen for the systolic reading through heard the first occurrence of rhythmic sounds	45(15)	8(2.7)	287(95.6)	289(96.3)	9(3)	2(0.6)	5.61	<0.05
-Listen and note for the Diastolic Reading as the BP cuff pressure drops and the sounds fade.	2(0.6)	2(0.6)	289(96.3)	288(96)	6(2)	6(2)	6.12	<0.05
- Slowly Deflate the BP cuff: should fall at 2 - 3 mmHg per second, anything faster may likely result in an inaccurate measurement.	0	19(6.3)	278(92.7)	286(95.3)	7(2.3)	7(2.3)	5.16	<0.05
- Double check for accuracy by taking a reading with both arms and averaging the readings and wait five minutes between readings.	79(26.3)	44(14.7)	249(83)	259(86.3)	33(11)	8(2.7)	4.98	<0.05

Table 4 The study revealed a statistically significant difference in the adolescents’ practice of taking blood pressure measurements after undergoing the healthy lifestyle program. Adolescents garnered a score of 100 percent for the best practice of using a stethoscope when taking blood pressure measurements and forstaying silent while taking blood pressure readings.

Figure 6

Difference of adolescents’ total levels of practice before and after the healthy lifestyle program according to their gender

Figure 6: The study showed a marked improvement of 96 percent among female adolescents’ total level of practice compared to their male counterparts’ lower score of 93 percent after undergoing the healthy lifestyle program.

Discussion

This research seeks to test the hypothesis that participation in a healthy lifestyle programme instigates behavioral change in hypertensive adolescents with vitamin D deficiency endeavouring to manage their blood pressure levels and enhance their vitamin D intake. Findings from this study revealed a statistically significant difference in adolescents’ knowledge and practices pre- and post-participation in the program. In addition, a significant correlation was evident between healthy lifestyle behavior at baseline and following completion of the programme in this adolescent sample, based on a number of specific demographic characteristics.

The current research identified that 34% of hypertensive adolescents had a first-degree relative with a history of obesity. Analysis of the prevalence of hypertension in children attending public schools in a Brazilian cohort reported a significant relationship between nutritional status and increased systolic and diastolic blood pressure, with this pattern being more pronounced in children who were overweight.28 In addition, children classified as obese were most likely to display elevated blood pressure readings. Similarly, an investigation of blood pressure management in a United States-based sample of children reported that obesity, smoking and lifestyle factors, such as lack of physical activity and a sedentary lifestyle, were associated with increased blood pressure, even among young children in the preschool years.29 The majority of participants in this study also reported a family history of high blood pressure, thus highlighting the requirement to monitor blood pressure levels from three years of age onwards.

The current research demonstrates positive health-enhancing behaviours among hypertensive adolescents who had completed a lifestyle programme. The majority of respondents 96.3% and 89.3% committed to undertaking physical exercises for between 30–60 minutes two to three days per week.30 identified a number of health benefits associated with engaging in physical activity programmes within school settings for young people aged between 6–18 years. The latter authors advocate for the ongoing promotion of physical exercise in light of the strong evidence base to support positive lifestyle habits and physical health status. Conversely, sedentary behaviour can lead to high blood lipid levels and hypertension among children. Based on a sample comprising 496 Greek adolescent students in the 12–17 years age group,31 recommended the integration of moderate intensity activities into young people’s daily lives. Subsequent research undertaken by32 on a United States-based child and adolescent cohort presenting with hypertension and vitamin D deficiency advised that they embrace a number of lifestyle changes in order to reduce their high blood pressure levels. This included referral to an intensive behavioural intervention programme adopting a broad-based and family-focused approach, which incorporated participating in sporting activities and regular physical exercise, as well as promoting the maintenance of a healthy diet. The findings from research conducted by33 concur with the current study, where the former examined the lifestyle patterns, diet and exposure of New York dwellers to sunshine as a source of vitamin D. They reported that intake of the recommended daily allowance of vitamin D was associated with the adoption of multiple strategies, including good nutrition, sunlight and consuming fortified foods and supplements. However, greatest impact in terms of hypertension was achieved by maintaining a healthy diet which is low in sugar and sodium, an outcome consistent with the current research findings. Exposure to natural sunlight or ultraviolent B irradiation was identified as the most effective lifestyle-related means of sourcing vitamin D.34 contend that the programme they devised successfully instigated positive lifestyle behavioural change among their sample characterised by high blood pressure and vitamin D deficiency, thus helping them to maintain normal blood pressure levels.

The current research found that a statistically significant relationship occurred between this adolescent cohort’s capacity to maintain a healthy lifestyle and a number of sociodemographic factors. These include: being female; within the 14–18 years age group; attending secondary school; of average socioeconomic status; and exposed to healthy environmental conditions. The proportion of male adolescents engaging in a healthy lifestyle following completion of a behaviour management programme was influenced by the following factors: aged between 11–14 years (90%); being physically active (60%); and of low socioeconomic status (55.7%). This concurs with outcomes from research undertaken by35 in the central Iranian city of Isfahan, which investigated the relationship between hypertension and socioeconomic factors. The latter authors reported a correlation between average socioeconomic status and the maintenance of a normal body weight, while also remaining physically active. In the case of female adolescents that urban dwellers classified as being of average or low health status tended not to be underweight. Furthermore, earlier work has shown that a strong correlation exists between the capability to sustain a healthy lifestyle and social class, which was based on two variables, namely education and income. Current research findings are also in line with those emanating from another Iranian study conducted by36, which sought to establish hypertension prevalence rates, as well as the relationship between this condition and various demographic determinants, biochemical markers and anthropometric measurements. Education was identified as a key predictor in the adoption of a healthy lifestyle, while being an urban dweller was also a strong influencing factor. The authors have argued that as adolescents grow and mature, in combination with being exposed to a positive healthy environment with sufficient income levels, both their awareness and capacity to maintain a healthy lifestyle increases. These determinants impact favourably upon their blood pressure management strategies, along with also addressing their vitamin D deficiencies.

The current study found that a statistically significant difference occurred between adolescents’ knowledge levels pre- and post-participation in a healthy lifestyle programme. This was evidenced by 90% reporting having acquired good knowledge levels, while 71% were aware of the signs and symptoms associated with hypertension, as well as strategies to implement to prevent complications arising from this condition. These findings concur with an earlier study undertaken in the White Nile Sudanese state by37, who investigated the impact of participation in a health education programme on attendees’ knowledge of hypertension, along with recommended management techniques. Significant increases in accurate knowledge regarding various hypertension-related elements were noted among those who had completed the programme (p < 0.001). This included knowledge regarding dietary management, clinical symptomatology, hypertension-related complications and the recommended levels of physical activity. Similar findings emerged in Brazilian-based research conducted by38 exploring the impact of educational programmes on blood pressure management among a hypertensive cohort. The outcomes were found to be positive, with participants demonstrating: increased knowledge levels, including in relation to deterioration characteristics and complications sequence; favourable attitudes towards hypertension management; and greater willingness to comply with therapeutic interventions. These findings are indicative of improved awareness of hypertension and vitamin D deficiency, thus increasing capacity to manage blood pressure readings, along with ensuring adherence to intake of recommended daily vitamin D allowances.

Findings two months post-completion of the current study’s healthy lifestyle programme revealed that both male and female adolescents who were implementing its recommendations had brought their blood pressure readings under control. Similar results were reported by 19, where White Nile Sudanese state residents attending health education programmes improved both their knowledge and management of their hypertension condition. Post-participation monitoring revealed that 92% of attendees had acquired sufficient knowledge levels to instigate positive lifestyle modifications in relation to diet and exercise, resulting in effective blood pressure management and considerable weight loss. These outcomes also concur with earlier research undertaken by 39exploring the correlation between blood pressure readings and fruit, fruit juice and vegetable intake in a random sample comprising 794 adolescents drawn from 12 different private schools based in the northeast region of Brazil. Twice daily consumption of fruit was associated with reduced systolic and diastolic blood pressure readings. However, vegetable intake instigated a more significant decrease in systolic blood pressure. The current study results are in accordance with those of40, where their research demonstrated the positive benefits associated with education programmes in terms of blood pressure management and the maintenance of healthy lifestyle behavioural change in a Turkish-based sample. The current research showed that the majority of adolescents initially presenting with vitamin D deficiencies, measured using a 25-hydroxy vitamin D blood test, progressed from insufficient to optimal levels, as documented in their medical notes two months post-completion of the healthy lifestyle programme. A quasi-experimental research design adopted by41 produced similar findings involving 175 girls within the 12–14 years age group, who were attending primary care services in Gonabad in Iran. They noted that, in contrast to the control group, participants assigned to the intervention condition implemented a range of behavioural changes conducive to improving their vitamin D intake, thus resulting in significantly positive effects (p < 0.001).

42 reported positive outcomes having conducted a randomised clinical trial involving the self-measurement of blood pressure among an urban New York-based adolescent cohort. The aneroid manometer was deemed to be a suitable device to use at home for those aged between 4–18 years. This sample demonstrated high-level skills following appropriate training in this monitoring method. These findings are in line with the current research, whereby self-measurement of blood pressure levels post-completion of the healthy lifestyle program resulted in statistically significant positive practices among adolescents, when compared with baseline measures. Best practice was adhered to in all cases in terms of blood pressure measurement post-participation in the education program, including teaching the adolescents stethoscope and blood pressure instrument usage, along with ensuring no talking took place during the readings. Imparting key skills including pulse measurement in the upper arm was found to be effective in the monitoring and management of their blood pressure levels. It is the researcher’s contention that the increased prevalence of hypertension among children can be attributed to a rise in obesity levels, sedentary lifestyles and nutritional deficiency. This research clearly underlines the vital importance of promoting physical activities and vitamin D supplement intake, along with maintaining a healthy lifestyle.

Conclusion and Recommendations

The study has reached the conclusion that the healthy lifestyle program was able to successfully modify the adolescents’ healthy lifestyle knowledge and practices which in turn enabled them to manage and control their hypertension and vitamin D deficiency. The study also helped the researcher gain a better understanding on how demographic factors affect the adolescents’ capability to manage and control their hypertension and vitamin D deficiency.

The study recommends further research and continuous promotion of a healthy lifestyle program for hypertensive adolescents who are deficient in vitamin D.

It also strongly recommends the development and establishment of programs and policies that promote physical activity and reduce sedentary behaviours. The study also endorses the promotion of healthy nutrition among children of different age groups.

The study recommends regular screening for hypertension among children and that school health programs should include a regular practice of taking blood pressure measurements.

One other recommendation that the study suggests is for nurses to have the added responsibility of promoting an awareness campaign on the dangers of vitamin D deficiency among mothers.

Ethics Approval and Consent to Participate

The study received ethical approval from adolescent, nursing students, and Nurses voluntarily participated in the study and completed a consent form prior to answering the questionnaire. In case of minors, informed consent was obtained from the legal guardians. All methods were conducted in accordance with relevant guidelines and regulation.

Availability of Data and Materials

All data generated or Analyzed during this study are included in this published article.

Authors' Contributions

Designed the research study, Analyze the data, and wrote the paper

Source of Funding

There no funding grant

Conflict of Interest

The author declare no competing interest