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(Circulation. 1996;93:60-66.) © 1996 American Heart Association, Inc.


Blood Pressure in Young Blacks and Whites: Relevance of Obesity and Lifestyle Factors in Determining Differences
The CARDIA Study
Kiang Liu, PhD; Karen J. Ruth, MS; John M. Flack, MD; Rhonda Jones-Webb, DrPH; Gregory Burke, MD; Peter J. Savage, MD; Stephen B. Hulley, MD
From the Department of Preventive Medicine, Northwestern University Medical School, Chicago, Ill (K.L., K.J.R.); the Hypertension Center, Bowman Gray School of Medicine, Winston-Salem, NC (J.M.F.); the Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis (R.J.-W.); the Department of Public Health Sciences, Bowman Gray School of Medicine, Winston-Salem, NC (G.B.); the Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md (P.J.S.); and the Department of Epidemiology and Biostatistics, University of California at San Francisco (S.B.H.). Correspondence to Kiang Liu, PhD, Department of Preventive Medicine, Northwestern University Medical School, 680 N Lake Shore Dr, Suite 1102, Chicago, IL 60611.

Top Abstract Introduction Methods Results Discussion References

Background Middle-aged black men and women have higher blood pressure, on average, than whites. However, this pattern is inconsistent in children and adolescents. This study explores how differences in lifestyle factors in young adulthood may influence blood pressure patterns in the two races.

Methods and Results The Coronary Artery Risk Development in Young Adults (CARDIA) study is an ongoing collaborative investigation of lifestyle and the evolution of cardiovascular disease risk factors in a random sample of young adults ages 18 to 30 years at baseline (1985 to 1986). Data from four examinations over 7 years were analyzed with the use of a method that simultaneously examined cross-sectional and longitudinal relationships of lifestyle factors and blood pressure. This study included 1154 black women, 853 black men, 1126 white women, and 1013 white men. Blacks had higher systolic blood pressure and diastolic blood pressure than whites at every examination. Racial differences were much greater in women than in men and increased over time. Within each sex-race group, average diastolic blood pressure over four

data from the second National Health and Nutrition Examination Survey indicated that the prevalence Top rates of definite hypertension (systolic blood pressure [SBP] 160 mm Hg. Key Words: blood pressure • lifestyle • obesity • race Introduction Hypertension is a major public health problem in the United States. Longitudinal change in diastolic blood pressure was positively associated with changes in body mass index and alcohol intake. 6 7 8 9 10 11 12 13 Discussion for children and adolescents. Specifically. various aspects of lifestyle. One References plausible hypothesis is that during young adulthood. and psychosocial characteristics may differ between blacks and whites and subsequently contribute to evolving racial patterns of blood pressure. and intake of potassium and protein. Abstract diastolic blood pressure [DBP] 95 mm Hg and/or taking antihypertensive Introduction medication) in persons aged 55 to 64 years were 60% and 46% for black women Methods Results and men and 34% and 31% for white women and men. After adjustment for obesity and other lifestyle factors. especially in blacks. and alcohol intake and negatively associated with physical activity. Results for systolic blood pressure were similar.examinations was positively associated with baseline age. blacks have higher mean blood pressure and prevalence of hypertension than whites. This study presents an examination of this hypothesis using 7-year follow-up data from the CARDIA study.1 2 3 4 5 For example. respectively. obesity. Many studies have demonstrated that for middle-aged men and women. the results are inconsistent. data were analyzed for the following purposes: (1) to describe the black-white differences in 7-year blood pressure change in young adults. Conclusions Differences in obesity and other lifestyle factors in young adults largely explain the higher baseline blood pressure and greater increase over time of blacks relative to whites. (2) to determine factors that are associated with blood pressure change over time. and (3) to examine the degree to which the observed black-white differences in blood pressure change among young adults can be explained by the differences in these factors. black-white diastolic blood pressure differences were reduced substantially: 21% to 75% for men and 49% to 129% for women.3 However. cigarette use. body mass index. Methods .

Overall retention of the surviving cohort at the year 7 Results examination was 80%. 1058 white women. Within each sex-race group.The CARDIA study is a multicenter. Height and weight were measured with the participant wearing light clothing and no shoes. and 956 white men had completed all four examinations. lifestyle. those who were not in the study sample tended to be slightly younger (differences of 0.6 years). During the first 7 years of follow-up. However. wine. The cohort consisted of 5115 black and white men and women aged 18 to 30 years at baseline with varying levels of socioeconomic status. Alcohol intake (mL/d) was computed from the self-reported frequency of beer. Calif. and energy intake.5 cm and weight to the nearest 0. race. for each sex-race group. For the center in Top Abstract Oakland. physical activity score. and psychosocial characteristics. Four clinical centers conducted the baseline (1985 to 1986). reflecting aspects of overweight. Ill. a modified version of the Minnesota Leisure Time Physical Activity Questionnaire.19 These variables. Ala. 1043 black women. year 2 (1987 to 1988). slightly less educated (differences of 0. and 1013 white men who had References completed the baseline and at least two of three subsequent examinations. 1126 white women. Height was recorded to the nearest 0. Before each examination. 853 black men.16 Physical activity score was derived from the CARDIA Physical Activity History.18 Dietary protein (% kcal). participants were randomly recruited from the KaiserIntroduction Permanente health plan membership. Age at baseline was computed from the reported birth date. and Minneapolis. and potassium (mg/1000 kcal) were derived from the baseline and year 7 CARDIA dietary history. Sex. and number of cigarettes smoked per day were self-reported. Detailed descriptions of the design of the CARDIA study and baseline blood pressure differences between blacks and whites have been published elsewhere. After a 5-minute rest in a quiet room. were selected because they have been reported to be associated with blood . longitudinal study on lifestyle and evolution of cardiovascular disease risk factors.4 to 0. For the centers in Birmingham. The study sample used in the analyses included 1154 Discussion black women. Chicago.14 15 All measurements were taken by trained and certified technicians according to the CARDIA manual of operations.8 years). Among them. BMI was calculated as weight (kg) divided by height squared (m2). 41 Methods participants died. years of education. 752 black men. The average of the second and the third blood pressure measurements was used in the analyses. comparisons of baseline characteristics between those who were in the study sample and those who were not indicated that the two groups were similar with respect to blood pressure. and year 7 (1992 to 1993) examinations. participants were asked to fast for 12 hours and to avoid smoking and heavy physical activity for 2 hours. participants were randomly recruited from the total community or from selected census tracts in the community.17 A hostility score was calculated as the sum of the `hostile' responses on the 50-item Cook-Medley subscale of the Minnesota Multiphasic Personality Inventory (MMPI). year 5 (1990 to 1991). calcium (mg/1000 kcal). an interviewer-administered quantitative food frequency questionnaire.2 lb. and were more likely to smoke cigarettes.6 to 0. Minn. and liquor consumed per week. body mass index (BMI). three systolic and fifth-phase diastolic blood pressures were measured at 1-minute intervals on the participant's right arm with the use of a random zero sphygmomanometer. alcohol intake.

For each sex-race group. Within each sex group. The coefficient ß3 measures the average difference in SBP between those who are on antihypertensive medication and those who are not on medication. and eit is the error term. Similarly.pressure. Ui is a time-independent covariate (baseline age). 7. and Xit=0 otherwise). The coefficient ß2 measures the association between the SBP (averaged over time) and baseline age adjusting for other covariates. A more detailed description of the methods was published in the CARDIA baseline monograph. 5. for t=0. the coefficient ß4 measures the relationship between the average SBP and baseline weight adjusting for other covariates. one can use three dummy variables to separate the four time points and one dummy variable to separate the two race groups. Xit is a time-dependent covariate for the ith person at time t (for example. Yit is the SBP for the ith person at year t. 5. a typical model is where for t=0. Zi0 is the baseline value of a time-dependent covariate (baseline weight). The coefficient ß1 measures the average annual change in SBP adjusting for the covariates. 2.33 The longitudinal analyses were based on the Generalized Estimating Equation method developed by Liang and Zeger. the change in weight between year t and baseline for the ith person). Results . Xit=1 if the ith person is on antihypertensive medication. 7.15 16 20 21 22 23 24 25 26 27 28 29 30 31 32 Quality of the data collection was monitored by the Coordinating Center and the CARDIA Quality Control Committee throughout the four examination periods. Zit=Zit-Zi0 (that is.34 35 This method simultaneously examines the cross-sectional relationship between each of the independent variables and blood pressure and the relationship between changes in these variables and changes in blood pressure. in addition to the race-specific model. The three cross-product terms between the variables for time and race provide the different racial patterns of changes in SBP over time. 2. The coefficient ß5 measures the relationship between changes in weight and changes in SBP over time.

0% in black women and white men). the black-white differences increased from 1. Blacks were on average 1 year younger than whites. The baseline Discussion average BMI was comparable between black and white men. Similar to DBP. calcium. the average DBP decreased somewhat at year 2 and then increased at years 5 and 7. and protein intakes than whites.6 mm Hg at baseline.9.Comparison of Baseline Characteristics The baseline characteristics of the participants are provided in Table 1 . year 5. The decreases at year 2 were presumably due to the adaptation effect. 4. the number of cigarettes smoked per day was higher in whites than in blacks. the average SBP decreased at year 2 and then increased at years 5 and 7. For men.2. The average education level was lower in blacks than in whites. reaching 3.6 mm Hg at baseline to 3. Top Abstract the average DBP level was similar for black and white men and was slightly but Introduction significantly higher in black women than in white women.0 mm Hg at year 2. and year 7.8 mm Hg at year 7. For black women. For both men and women.1 mm Hg at baseline to 2. . the intake per day was similar for the two racial groups. The prevalence of cigarette smoking was higher in blacks than in whites. For women. however. View this table: Table 1.4 to 6. On the other hand.4% in white women to 1. average SBP was higher in blacks than in whites. however.1 mm Hg at year 5. 1. respectively.6 mm Hg at year 7. the difference increased from 3. the average SBP continued to decrease even at year 5 and then increased at year 7 (Fig 1 ).4. this difference was fairly large in women. The average physical activity score was similar for black and white men but was much lower in black women than white women. year 2. the black-white difference in SBP increased over time. For women. white men. for smokers.6 mm Hg. black References women were on average much more obese than white women. the black-white differences in average DBP were -0. Baseline Characteristics of the Cohort by Sex and Race [in this window] [in a new window] Black-White Difference in Blood Pressure Over Time Fig 1 presents the black-white difference in blood pressure over time for men and women. For men. and 1. however. for drinkers. and white women. The prevalence of alcohol drinking was higher in whites than in blacks.4 mm Hg. the difference increased from 1. Few people in the Methods four sex-race groups reported antihypertensive drug treatment (ranging from Results 0. 1. and 4. Blacks had higher hostility scores and lower potassium. For three of four sex and race groups. For black men.

Thus. The estimated coefficient between a baseline variable and blood pressure can be viewed as the difference in DBP averaged over 7 years corresponding to per unit difference in this variable after adjusting for the longitudinal relationship. Each sex-race group was analyzed separately. and change) were included simultaneously in the same model. 2. however. The coefficient measures the average difference in DBP between persons with treatment and persons without treatment (including normotensive) at the four time points. each column represents a separate analysis. Baseline alcohol intake was positively associated with DBP in all groups. Factors Associated With DBP and Changes in DBP: Regression Coefficient From Generalized Estimated Equation Analyses The coefficient of time reflects the average change in DBP per year (Table 2 ).Figure 1. or protein intake and DBP. Plot of average systolic blood pressure (SBP) and diastolic blood pressure (DBP) (mm Hg) at each CARDIA exam (years 0. Baseline potassium intake was significantly negatively associated with DBP in white women. the positive coefficient indicates that on average DBP increased slightly over the 7-year period. hostility score. Baseline physical activity score was significantly negatively related to DBP in men but not in women. For whites. The results indicate that except for white women. Within each sex-race group. the three types of variables (baseline. and 7) for black and white men (left) and black and white women (right). 5. for hypertensive . For blacks. the relationship was significant in black men only. Antihypertensive drug treatment was a time-dependent variable. average DBP decreased slightly over this period. No consistent associations were observed between baseline education. View this table: [in this window] [in a new window] Table 2. calcium intake. persons on antihypertensive drug treatment had significantly higher DBP than persons not on treatment. View larger version (24K): [in this window] [in a new window] Factors Associated With Blood Pressure and Changes in Blood Pressure Table 2 presents the results of the longitudinal analyses for DBP. time-dependent. Baseline age and BMI were significantly positively associated and baseline cigarette smoking was significantly negatively associated with DBP in all sex-race groups.

subjects on treatment. 2. For women. Thus. and lifestyle factors listed in Tables 2 and 3 . The only exceptions were that the baseline number of cigarettes smoked per day was unrelated to SBP. the baseline hostility score was inversely associated with average SBP in white men and women.3 to 1. Change in BMI was significantly related to change in DBP in every sex-race group (Table 2 ). none of the correlations was statistically significant (data not shown). However. protein. 4. the black-white differences in DBP were reduced from 0. blood pressure was not normalized to a level similar to that of normotensive subjects.4 mm Hg (-129%) at baseline. and 2.4 to -0. On the other hand.4 to 0. . black-white differences in DBP were reduced for both men and women as compared with the differences in DBP adjusting for baseline age and antihypertensive treatment status only (Figs 2 and 3 ). obesity. Factors Associated With SBP and Changes in SBP: Regression Coefficient From Generalized Estimated Equation Analyses Impact of Obesity and Lifestyle Factors on Black-White Differences in Blood Pressure With adjustment for baseline age. For most variables. the associations with SBP were generally similar to those with DBP (Table 3 ).9 to 1. the longitudinal associations could not be determined. 1.1 mm Hg (-75%) at baseline. 2. Change in alcohol intake was significantly positively associated with change in DBP in white men and women and black women. antihypertensive treatment status. View this table: [in this window] [in a new window] Table 3.5 (49%) at year 7 (Fig 3 ). or calcium intake and changes in DBP or SBP. Since the dietary variables and hostility score were not collected at every examination.0 to 1. For men. and 4. and age was related to average SBP in black women only.9 (-56%) at year 5.2 (-40%) at year 7.6 (-30%) at year 5.3 to 1. in a separate analysis to assess the relationships between 7-year changes in potassium. 49% of the observed black-white difference in DBP at year 7 in women and 40% in men were explained statistically by black-white differences in obesity and lifestyle factors.5 (-21%) at year 2.9 to 2. changes in the number of cigarettes smoked per day and physical activity score were not associated with change in DBP. the reductions were from 1.3 (-88%) at year 2.4 to 0. Similar results also were observed for SBP (data not shown).

in all four sex-race groups. education. the blood pressure difference was very small at baseline and gradually increased over time. alcohol. cigarettes. hostility. In addition. physical activity. body mass index. 2. Line graph shows adjusted diastolic blood pressure (DBP) (mm Hg) in black (B) and white (W) men at year 0. potassium intake. and protein. respectively. calcium intake. and 7 CARDIA examinations (left axis). Bar graph shows the black-white difference in adjusted DBP (mm Hg) at each examination (right axis). certain lifestyle factors and changes in these factors were also related to blood pressure or changes in blood .View larger version (22K): [in this window] [in a new window] Figure 2. View larger version (20K): [in this window] [in a new window] Figure 3. For both men and women. These data were further analyzed with additional adjustment for center. Light line and light bars indicate further adjustment for age. and protein. education. adjusting for center did not change the results for the black-white differences (data not shown). Even though the average blood pressure differed among the four centers. body mass index. Line graph shows adjusted DBP (mm Hg) in black and white women at year 0. Bar graph shows the black-white difference in adjusted DBP (mm Hg) at each examination (right axis). physical activity. BMI and BMI change were strongly associated with blood pressure and blood pressure change. hostility. Dark line and dark bars indicate adjustment for age and antihypertension medication use. See Fig 2 for abbreviations. 5. 2. alcohol. Dark line and dark bars indicate adjustment for age and antihypertensive medication use. calcium intake. cigarettes. 5. Light line and light bars indicate further adjustment for age. potassium intake. Discussion Top Abstract Introduction Methods Results Discussion References This study examined the black-white difference in blood pressure change during young adulthood. and 7 CARDIA examinations (left axis).

at most. however. BMI was significantly associated with average DBP in every sex-race group20 . 0. smokers tend to be leaner.3 mm Hg for black women. very small differences in blood pressure when participants were young.23 The results in CARDIA confirmed the cross-sectional relationship between cigarette smoking and blood pressure. Given that approximately 45% of the black-white differences in blood pressure at year 7 were explained by major environmental factors. longitudinally. It has also been hypothesized that the inverse relationship may be explained by depressor effects of cotinine. the longitudinal findings indicated that for young adults. studies on middle-aged adults have clearly indicated that blacks have a higher average blood pressure and prevalence of hypertension than whites. the black-white difference in blood pressure was substantially reduced.25 In CARDIA. Even if smoking does lower blood pressure slightly. With adjustment of BMI and lifestyle variables. for prevention of hypertension. it is important to prevent weight gain in young adulthood while blood pressure levels are still mostly in the normal range and participants are not yet significantly obese. Habitual physical activity has been inversely associated with blood pressure in other studies. These results suggest that for prevention of the age-related rise in blood pressure. Patterns of Black-White Differences in Blood Pressure Previous studies on the difference in black-white blood pressure levels suggest that the pattern varies with age.0 mm Hg for white men. It is possible that the effect of obesity on blood pressure is not completely removed by statistical adjustment for weight or BMI.5 mm Hg for black men. Factors Related to Blood Pressure Consistent with results from other studies. However. and ultimately of hypertension. the baseline physical activity score was inversely related to blood pressure in men but not in women. An inverse cross-sectional relationship between cigarette smoking and blood pressure independent of weight or BMI has been reported by many studies. blood pressure increased (or decreased) as alcohol intake increased (or decreased). it should be avoided for its well-known adverse effects on health. The differences increased over time as participants aged. and 0. 1. For example.15 This report presents the longitudinal data to confirm that there were. This suggests that alcohol intake should be minimized. in addition.1 2 3 4 5 Previous reports of the CARDIA baseline cross-sectional data suggest that the average blood pressure levels of blacks and whites start to diverge during young adulthood and that the difference increases with age. BMI change was strongly associated with DBP change in every sex-race group.6 7 8 9 10 11 12 13 However. among other reasons. for an increase in BMI for one unit.16 21 22 In CARDIA. an association that was stronger in whites than in blacks. Reported differences are inconsistent among children and adolescents. Alcohol consumption has been shown by many studies to be a risk factor for hypertension. these results suggest that black-white differences in obesity and lifestyle factors during young adulthood impact on the divergence of blood pressure over time.23 24 In general.6 mm Hg for white women. the baseline alcohol intake was only weakly associated with the average blood pressure during young adulthood. and there was no relationship between change in physical activity score and change in blood . there was no relationship between changes in the number of cigarettes smoked per day and the changes in blood pressure.pressure. the average change in DBP was 0.

racial discrimination) may be related to the residual black-white difference in blood pressure.32 Impact of Obesity and Lifestyle on the Black-White Difference in Blood Pressure The data from this study indicate that obesity and certain lifestyle factors. Furthermore.15 In addition. most of the lifestyle factors used in this study are based on self-reported data and may have large measurement errors. potassium. baseline education was not associated with blood pressure. The psychosocial variables used in the analyses were education and hostility score. These results are consistent with other studies that have shown no relationship between calcium intake and blood pressure. are responsible for a large proportion of the black-white difference in blood pressure. several important factors (for example. due to lack of data. alcohol drinking and lack of physical activity. a residual black-white difference in blood pressure remains after adjusting for these factors. However. It is unlikely that the reduction in the black-white difference was biased by the exclusion of participants from the original cohort.28 29 In CARDIA.pressure. The lack of relationship may in part be due to attenuation caused by the inaccuracy of the self-reported physical activity data.30 In CARDIA. sodium. none of the coefficients attained statistical significance. sodium intake and certain psychosocial characteristics such as psychosocial stress or anxiety). were not measured and could not be included in the analyses. urinary sodium excretion was collected only in a subgroup of participants and therefore could not be included in the analysis. Measurement errors would attenuate the association between lifestyle factors and blood pressure and thus underestimate the reduction of a blackwhite difference in lifestyle factor–adjusted blood pressure. the 7-year change in calcium intake was not correlated with the 7-year change in blood pressure. Approximately 19% of the participants were excluded from the analyses if they had missed two or more examinations. Certain stressors associated with minority status (for example. Second.38 Fourth. Unlike the results of many other studies. Several studies have shown that blacks with darker skin tend to have higher blood pressure.26 27 28 29 30 Due to practical difficulties. although protein intake was inversely associated with average blood pressure in every sex-race group. in CARDIA. the black-white difference also may be influenced by genetic factors. and protein have been found or hypothesized to be associated with blood pressure. There are several hypothetical explanations for this difference. A recent finding from the INTERSALT study suggests that protein intake is inversely associated with blood pressure. for example. Comparisons of baseline . Third.31 In this young adult cohort. Several dietary factors including calcium. First. baseline potassium intake was significantly inversely related to average blood pressure only in white women and (borderline significant) in black men. in CARDIA. similar to the findings of another study. the CARDIA data do not support the hypothesis that hostility is associated with hypertension.27 Many cross-sectional studies have reported an inverse relationship between potassium intake and blood pressure. baseline education is a less precise indicator of socioeconomic status because some participants were still going to school and others might go back to school in the future.36 37 38 Blacks with darker skin also may be exposed to greater discrimination and poverty. nor was it related to the 7-year average blood pressure. race may independently predict blood pressure change. Baseline calcium intake was not related to baseline blood pressure.

N01HC-48050. Despite these problems. Received May 16. DBP. Hypertension. education and prevalence of hypertension. 1995. the difference was reduced by more than half. N01-HC-48049. The relatively weak associations between these variables and blood pressure suggest these differences are unlikely to bias the results. The authors would like to thank Dr Philip Greenland for his helpful suggestions. No. . US Department of Health and Human Services publication No. 234. education. and most important. limited or no alcohol drinking. avoidance of weight gain. Blood pressure level in persons 18-74 years of age in 1976-80. treatment. and N01-HC-95095 from the National Heart. accepted August 14.7:457-468. For age. BMI. N01-HC-48048. 1986. Hypertension Detection and Follow-up Program Cooperative Group. those who were included and those who were excluded were similar with respect to all important variables such as SBP. and control in the United States. and physical activity. 1985. Hypertension prevalence and the status of awareness. [Abstract/Free Full Text] 2. [Abstract/Free Full Text] 3. and cigarette smoking. after adjusting for obesity and lifestyle factors. the black-white difference was reduced both in men and women. 1977. References Top Abstract Introduction Methods Results Discussion References 1. Lung. 1995. Acknowledgments This study was supported by contracts N01-HC-48047. revision received August 7.106:351-361. (PHS) 86-1684. These results suggest that it is important to establish a healthy lifestyle during young adulthood including regular exercise.characteristics indicated that within each sex-race group. Am J Epidemiol. for women. and Blood Institute. 1995. and trends in blood pressure from 1960 to 1980 in the United States: data from the National Health Survey series 11. small differences were observed for both blacks and whites. alcohol intake. Race.

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