ORIGINAL ARTICLE

Ethnic Differences in the Prevalence of Hypertension in

Colombia: Association With Education Level

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Jose P. Lopez-Lopez,1 Daniel D. Cohen,1 Natalia Alarcon-Ariza,1 Margarita Mogollon-Zehr,1
Daniela Ney-Salazar,2 Maria A. Chacon-Manosalva,1 Daniel Martinez-Bello,1 Johanna Otero,1
Gabriela Castillo-Lopez,3 Maritza Perez-Mayorga,1,4 Sumathy Rangarajan,5 Salim Yusuf,5 and
Patricio Lopez-Jaramillo1,2,

BACKGROUND CONCLUSIONS
A higher prevalence of hypertension is reported among Afro-descendants We found that a higher prevalence of hypertension in Colombian
compared with other ethnic groups in high-income countries; however, Afro-descendants than other ethnic groups. This was principally asso-
there is a paucity of information in low- and medium-income countries. ciated with their lower mean educational level, an indicator of lower
socioeconomic status.
METHODS
We evaluated 3,745 adults from 3 ethnic groups (552 White, 2,746 Mestizos,
447 Afro-descendants) enrolled in the prospective population-based co-
GRAPHICAL ABSTRACT
hort study (PURE)—Colombia. We assessed associations between anthro-
pometric, socioeconomic, behavioral factors, and hypertension.

RESULTS
The overall prevalence of hypertension was 39.2% and was higher in
Afro-descendants (46.3%) than in Mestizos (37.6%) and Whites (41.5%),
differences that were due to the higher prevalence in Afro-descendant
women. Hypertension was associated with older age, increased body
mass index, waist circumference and waist-to-hip ratio, independent
of ethnicity. Low education was associated with hypertension in all
ethnic groups, and particularly in Afro-descendants, for whom it was
the factor with the strongest association with prevalence. Notably, 70%
of Afro-descendants had a low level of education, compared with 52%
of Whites—26% of Whites were university graduates while only 7% of
Afro-descendants were. We did not find that education level alone had Keywords: Colombia; education level; ethnicity; hand grip strength;
a mediator effect, suggesting that it is not a causal risk factor for hyper- hypertension
tension but is an indicator of socioeconomic status, itself an important
determinant of hypertension prevalence. https://doi.org/10.1093/ajh/hpac051

The overall worldwide prevalence of hypertension in adults
is estimated to be 31.1% and the majority of the approxi-
mately 1.3 billion people affected live in low- and middle-
income countries (LMICs).1,2 This disproportionate burden
in LMICs could be explained by multiple sociodemographic,
economic, and behavioral factors. Ethnicity is one of the
factors proposed to contribute to these differences, with ev-
idence from large population studies such as the National
Health and Nutrition Examination Survey (NHANES)
showing a greater prevalence of hypertension in African
Americans than non-Hispanic Whites, Hispanic and
Asians.3–5 However, less information is available in LMICs
such as Colombia, a multiethnic middle-income country.6,7
Therefore, this study aimed to determine the prevalence of
hypertension across the 3 ethnic groups that predominate
in Colombia: White, Mestizo, and Afro-descendant, and

1Instituto MASIRA. Universidad de Santander (UDES), Bucaramanga,

Correspondence: Patricio Lopez-Jaramillo (jplopezj@gmail.com).
Initially submitted January 24, 2022; date of first revision March 12, 2022;
accepted for publication April 12, 2022; online publication April 16, 2022.
Colombia; 2Fundación Oftalmológica de Santander, Floridablanca,
Colombia; 3Facultad de Medicina, Universidad de Buenos Aires, Buenos
Aires, Argentina; 4Facultad de Medicina, Universidad Militar Nueva
Granada, Bogotá, Colombia; 5Population Health Research Institute,
Hamilton, Canada.

© The Author(s) 2022. Published by Oxford University Press on

behalf of American Journal of Hypertension, Ltd. All rights reserved.
For permissions, please e-mail: journals.permissions@oup.com

American Journal of Hypertension 1

Lopez-Lopez et al.
evaluate associations with socioeconomic, metabolic, an-
thropometric, and behavioral factors which could contribute
to potential differences.
METHODS
Population and study design
Data from the Colombian subjects included in the global
Prospective Urban Rural Epidemiology (PURE) study were
analyzed.8 With the aim of obtaining an adequate geographic
and social representation, participants were selected from
Colombian urban and rural communities from 11 of the
most populated departments (Atlántico, Bolívar, Caldas,
Casanare, Cauca, Cesar, Cundinamarca, Nariño, Quindío,
Santander, and Tolima) that comprise 51.29% of the
Colombian population as previously described.9 Briefly, a
multistage convenience sample survey was used. During the
first and second stages, the departments and communities
were selected. In the third stage, a representative sample
of households was recruited, using a community-sampling
framework. Households were eligible if at least one
member was 35–70 years old and if the members intended
to continue living at that address for 4  years or more. The
sociodemographic, behavioral characteristics, and health
status of all participants were collected in a specific format.
This report includes 3,745 adults between 35 and 70  years
of age with complete socioeconomic data and who by self-
recognition were assigned to an ethnic group based on the
parameters used by the Colombia’s National Administrative
Department of Statistics (DANE).7 The local ethics
committees approved the study protocol, and all participants
signed written consent.
Procedures
The sociodemographic characteristics of all consenting
participants, including date of birth, cardiovascular disease
(CVD) risk factors (such us smoking, hypertension, diabetes,
psychosocial factors, and alcohol consumption), monthly
income, and the use of home polluting cooking fuels (e.g.,
wood, charcoal, animal dung, coal) were recorded, and a
basic physical examination was performed. Blood pressure,
anthropometric, and handgrip measurements were taken.
Those with a university diploma were classified as having a
high educational level, a secondary or technical diploma as
a middle-level education, and those without a schooling his-
tory, primary or unknown education status as a low level of
education. Current smokers were those who reported con-
suming a daily tobacco product in the last 12  months or
reported quitting smoking in the last year. Self-reported al-
cohol abstinence was considered as a never drinker, former
drinkers as those having ceased alcohol consumption for a
year or more, and current drinkers as those who reported
alcohol consumption in the past year. We registered daily
meal consumption through a food frequency question-
naire (FFQ).10 Obtaining ethnic group data is typically a
complex process, due to its subjective nature-self-defined
ethnicity tends to evolve according to the context, in partic-
ular, of the social and political attitudes of the population.
2 American Journal of Hypertension
We used the self-recognition of membership of one of the
ethnic groups as Mestizo (a mix of White with aboriginal),
White, or Afro-descendant (including Black and a mix of
Black with White and Black with aboriginal), based on the
DANE recommendations.7 This implies that the individual
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recognizes themselves as belonging to one of the 3 ethnic
groups listed or none of them. It refers to the sense of belonging
that a person expresses in front of a collective according to
their identity and forms of interaction in and with the world.
History of hypertension or consumption of antihypertensive
medication was also recorded. Trained research assistants
used a sphygmomanometer (Omron HEM-757) with a
14 × 48  cm cuff to take blood pressure measurements.
Each participant was instructed not to consume any food
or drink, no cigarettes or alcohol consumption or physical
activity in the previous half-hour and was asked to rest in a
seated position 5 minutes before having their blood pressure
measurements. Blood pressure was taken twice, in the health
facility, with participants sitting upright and the right arm
supported at heart level, with a 5-minute interval between
each measurement. The mean of the 2 measures was used in
the analysis. Anthropometric measurements were acquired
following the PURE standardized protocol.8 Bodyweight
was obtained using a digital balance, ensuring the patient
was wearing light clothing, and height was obtained using
a measuring tape approximating each measurement to the
closest millimeter. The patient was instructed to be bare-
foot for both measurements. Waist circumference (WC)
and hip circumference (HC) were measured with tape over
the patient’s skin. Waist-to-hip ratio (WHR) was calculated
by dividing WC by HC and body mass index (BMI) by di-
viding body weight (in kilograms) by the height (in meters)
squared. Handgrip strength (HGS) was measured utilizing
a Jamar dynamometer (Sammons Preston, Bolingbrook,
IL) following the previously described protocol.11 Briefly,
participants were asked to stand, holding the dynamometer
on their body’s side with their elbow flexed at a 90° angle and
then asked to squeeze the instrument as hard as possible for
3 seconds. Each measurement was repeated 3 times after a
30-second resting interval. Participants were then classified
in tertiles according to their BMI, WHR, WC, and HGS. The
first urine sample of the morning was taken after a night of
fasting for determination of sodium and potassium. Samples
were frozen at −20°C to then be sent to the laboratory for
analysis using standardized methods. We used the Kawasaki
formula to estimate 24-hour sodium and potassium urine
excretion. This estimate has been validated as a substitute for
determining sodium and potassium (Na/K) daily intake.12
Statistical Analysis
A descriptive analysis estimating the measures of cen-
tral tendency and dispersion was carried out. Categorical
variables are presented as frequencies and percentages, and
continuous variables are presented as means and standard
deviations. The presence of hypertension, defined as a systolic
blood pressure (SBP) of 140 mm Hg or more, and/or a dias-
tolic blood pressure (DBP) of 90 mm Hg or more, or a previous
diagnosis of hypertension, or the use of antihypertensive

medications, was analyzed as a dichotomized categorical
variable. Participants were grouped according to their self-
identified ethnicity (Whites, Mestizos, Afro-descendant).
We developed 3 paths for the statistical analysis. First, we
analyzed separately White, Mestizos, and Afro-descendant
using univariate and multivariate Poisson regression models
with robust standard errors to evaluate the association
(prevalence ratios [PR] and 95% confidence intervals [95%
CI] between hypertension and sex, age, education level, BMI
by tertiles, WC by tertiles, WHR by tertiles, HGW by tertiles
(handgrip strength adjusted by body weight, calculating
tertiles separately for men and woman), location, income,
and solid fuel cooking. Second, we analyzed separately by
sex and self-identified ethnicity using univariate and multi-
variate logistic regression to evaluate the association of hy-
pertension to the same variables described above.
Third, we employed a mediation effects analysis (Baron
and Kenny model13) to evaluate the mediation effect of edu-
cation on the association of hypertension and ethnicity. The
variables used for the mediation analysis were hypertension
(binary response with 2 levels: yes, no), self-identified eth-
nicity (binary direct effect with 2 levels: Afro-descendant
and a composite of Mestizo and White), education (medi-
ator effect, with 3 levels: none, primary; secondary school;
and university), and using solid fuel cooking, sex, age, and
income as covariates. R statistical software version 3.6 was
employed for the analysis, and the mediation R package
version 4.5. Statistical significance was set at P < 0.05 for a
2-tailed test.
RESULTS
The analysis included 3,745 subjects from the PURE
Colombia study with well self-identified ethnicity and com-
plete information about socioeconomic factors, of which
63.5% were women and the mean age was 50.8 ± 9.4 years.
Overall, 73.3% of the population were defined as Mestizo,
14.7% as White, and 11.9% as Afro-descendant. Table 1
shows descriptive characteristics by self-identified ethnicity
group. In the whole population, only 12.6% had a high ed-
ucational level, been lowest in the Afro-descendant popu-
lation (7.8%) compared with Whites (26.6%) and Mestizos
(10.5%). There were no ethnic differences in cigarette
smoking, alcohol consumption, daily calories intake, fat,
protein, and Na/K intake. Most Whites lived in urban areas
(61.6%), while the majority of Afro-descendant (75.6%) and
Mestizos (58.2%) lived in rural areas. Income was different
between the self-identified ethnic groups with 81.2% of Afro-
descents, 70.8% of Mestizos and 48.4% of Whites having an
income lower that 350 USD. In the whole population the
mean SBP was 128.6 ± 21.8 mm Hg, and the mean DBP was
80.6 ± 13.1 mm Hg, and the prevalence of hypertension was
slightly higher in women (39.4%) than in men (38.5%). The
prevalence of hypertension in each ethnic group stratified by
sex is shown in Figure 1; a greater prevalence was observed
in Afro-descendant compared with Mestizos and Whites.
Table 2 shows the association between hyperten-
sion and sociodemographic factors and anthropometric
measurements, analyzed separately by self-identified
Ethnic Differences in the Prevalence of Hypertension in Colombia
ethnicity group. Based on the results of the multivariate
analysis, older age (>50 years) was associated with higher
prevalence of hypertension in all self-identified ethnicities.
In Mestizos, the upper tertile of BMI presented association
with higher prevalence of hypertension than participants
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in first tertile of BMI. White subjects in the middle tertile
of WC exhibited association with higher prevalence of hy-
pertension than participants in lower tertile of WC, while
in Mestizos, people on upper tertile of WC showed associ-
ation with higher prevalence of hypertension than subjects
in lower tertile. In Mestizos and Afro-descendants, those
with a low education level and Whites with low and middle
education levels displayed association for Mestizos and
Afro-Descendant respectively; and for middle education
level and for low education level in White subjects) with
higher prevalence of hypertension than subjects having
high education level.
In Mestizos, those with a monthly income below 350 USD
had significantly lower prevalence of hypertension compared
with participants with monthly income above 350 USD,
while in Afro-descendant participants, cooking using solid
fuel sources was associated with lower prevalence of hyper-
tension compared with cooking using other fuel sources.
Table 3 shows the results of the multivariate logistic re-
gression models fitted separately by sex and self-identified
ethnicity for the association of education effects with hy-
pertension, adjusted by the covariates described above.
We found that in female and male Whites and Mestizos,
and female Afro-descendants low education level was as-
sociated with high prevalence of hypertension compared
with subjects with high education level, while male Afro-
descendant did not show that association.
Table 4 shows the proportion of the mediator effect
obtained from the mediation analysis results for the associa-
tion of hypertension with self-identified ethnicity mediated
by education, and adjusted by age, sex, cooking with solid
fuels, and income. Model 1 did not reveal a mediator effect of
education level alone, but when home polluting cooking fuels
was included in the mediation model (Model 2), education
level exhibited an important proportion of mediation effect
(0.176, [95% CI: 0.059; 0.714]). We observed the same effect
on the proportion of the mediator effect when sex (Model
3) (0.192, [95% CI: 0.063; 0.724]) and age (Model 4) (0.135,
[95% CI: 0.046; 0.359]) were included, but the mediation
effect of education level disappeared when income was in-
cluded as a covariate (Model 5)  (−0.022, [95% CI: −0.135;
0.081]). These results could be explained by the strong as-
sociation existing between the income variable and cooking
with solid fuels (chi-square test of income cross-tabulated
with polluting cooking fuels, P < 0.001), making the model
estimates and results for the mediation effect of education
unstable when both variables (income and cooking with
solid fuels) are included in the mediation model. Model 6
replaces the variable of cooking using solid fuel by the in-
come variable, but the proportion of the mediator effect of
education level was not significant but close to the rejection
threshold (P = 0.062), supporting the idea that income is not
only associated with cooking with solid fuels, but also exerts
less influence on the mediator effect of education level on
the association of hypertension and self-identified ethnicity.
American Journal of Hypertension 3
Lopez-Lopez et al.

Table 1. Baseline characteristics of study participants according to ethnic groups: Whites, Mestizo, and Afro-descendant.

Characteristics Overall White Mestizo Afro-descendant

Participants, n (%) 3,745 552 (14.7) 2,746 (73.3) 447 (11.9)

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Age, years, mean (SD) 50.8 (9.40) 51.8 (9.29) 50.6 (9.44) 50.3 (9.23)
Sex
Men, n (%) 1,367 (36.5) 195 (35.3) 1,016 (37.0) 156 (34.9)
Women, n (%) 2,378 (63.5) 357 (64.7) 1,730 (63.0) 291 (65.1)
Location
Urban, n (%) 1,598 (42.7) 340 (61.6) 1,149 (41.8) 109 (24.4)
Rural, n (%) 2,147 (57.3) 212 (38.4) 1,597 (58.2) 338 (75.6)
Blood pressure measurement
SBP, mm Hg, mean (SD) 128.6 (21.8) 129.7 (22.0) 127.7 (21.4) 133.2 (22.9)
DBP, mm Hg, mean (SD) 80.6 (13.1) 81.2 (11.1) 80.0 (13.5) 83.1 (13.0)
Hypertension, n (%) 1,464 (39.1) 229 (41.5) 1,031 (37.5) 204 (45.6)
Anthropometric measurements
HGS, kg,mean (SD) 27.16 (10.53) 26.78 (9.59) 27.15 (10.71) 27.67 (10.73)
Height, cm, mean (SD) 158.4 (9.05) 158.9 (8.98) 157.8 (9.11) 161.7 (8.49)
Weight, kg, mean (SD) 66.1 (13.25) 67.0 (13.56) 65.6 (13.29) 68.0 (12.24)
BMI, kg/cm2, mean (SD) 26.35 (4.95) 26.55 (4.96) 26.36 (4.98) 26.06 (4.76)
WC, cm, mean (SD) 86.15 (11.36) 85.86 (11.74) 86.15 (11.25) 86.47 (11.59)
HC, cm, mean (SD) 97.21 (10.13) 97.28 (9.77) 96.72 (10.16) 100.17 (9.88)
WHR, mean (SD) 0.89 (0.09) 0.88 (0.09) 0.89 (0.10) 0.86 (0.08)
Education level
Low, n (%) 2,553 (68.2) 289 (52.4) 1,955 (71.2) 309 (69.1)
Middle, n (%) 721 (19.3) 116 (21.0) 502 (18.3) 103 (23.0)
High, n (%) 471 (12.6) 147 (26.6) 289 (10.5) 35 (7.8)
Behavioral characteristics
Cigarette smoking, n (%)
Never 2,491 (66.5) 356 (64.5) 1,811 (66.0) 324 (72.5)
Current 500 (13.4) 56 (10.1) 384 (14.0) 60 (13.4)
Ex-smoker 754 (20.1) 140 (25.4) 551 (20.1) 63 (14.1)
Consumption of alcohol, n (%)
Never 2,082 (55.6) 335 (60.7) 1,484 (54.0) 263 (58.8)
Current 1,102 (29.4) 145 (26.3) 808 (29.4) 149 (33.3)
Ex-drinker 561 (15.0) 72 (13.0) 454 (16.5) 35 (7.8)
Daily calories intake, mean 2,251 (1034) 2,219 (925) 2,269 (1058) 2,178 (1011)
(SD)
Na/K intake, mean (SD) 0.72 (0.23) 0.69 (0.22) 0.71 (0.22) 0.77 (0.27)
Fat intake, %, mean (SD) 18.29 (4.84) 18.80 (4.83) 18.28 (4.92) 17.74 (4.32)
Protein intake,%, mean (SD) 15.80 (3.27) 16.04 (3.01) 15.50 (3.16) 17.32 (3.80)
Solid fuel cooking n (%) 1,018 (27.2) 103 (18.7) 859 (31.3) 56 (12.5)
Income
≥350 USD, n (%) 1,170 (31.2) 285 (51.6) 801 (29.2) 84 (18.8)
<350USD, n (%) 2,575 (68.8) 267 (48.4) 1,945 (70.8) 363 (81.2)

Data are presented as the mean and standard deviation (SD) or as number (n) and percentage (%). Abbreviations: SBP, systolic blood pres-
sure; DBP, diastolic blood pressure; HGS, hand grip strength; BMI, body mass index; WC, waist circumference; HC, hip circumference; WHR,
waist-to-hip ratio; Na/K intake, sodium/potassium intake.

4 American Journal of Hypertension


Figure 1. Prevalence of hypertension among the ethnic groups: Mestizo, White, and Afro-descendent categorized by sex.
DISCUSSION
In this study, we describe hypertension prevalence in
a sample of Colombian subjects and establish the associa-
tion with sociodemographic, anthropometric, and met-
abolic variables. We found that the association between
self-identified ethnicity (categorized as White, Mestizo, and
Afro-descendant) with hypertension rates is mediated by
education level and influenced by socioeconomic disparities
such as income and cooking using solid fuel sources. In
this adult Colombian sample with a mean age of 50  years,
the overall prevalence of hypertension was 39.2% and was
slightly higher in women (39.7%) than in men (38.4%).
Prevalence was higher in Afro-descendants (45.6%) than in
Mestizos (37.5%) and higher than in Whites (41.5%). These
differences were due to the higher prevalence observed in
the Afro-descendant women, since in men differences be-
tween the ethnic groups were not evident. A previous study
in a Colombian population aged over 60 years showed that
the prevalence of hypertension was 57.7%, an expected dif-
ference given the older age of that study in comparison with
the present population. They used the color palette tool to
identify ethnicity and did not observe differences in prev-
alence by skin color but did find a higher prevalence in
women compared with men, particularly in dark-skinned
women.14 The different methods used to classify the ethnic
groups, to identify the hypertensive subjects (in Barrera,
year 95% was by interview) and difference in the mean
age of the sample may explain our contrasting findings.14
Although population studies such as the NHANES3–5 and
the Center for Disease Control and Prevention (CDC) da-
tabase in USA show a higher prevalence of hypertension in
Afro-Americans than in other ethnicities,15 ethnicity has
Ethnic Differences in the Prevalence of Hypertension in Colombia
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not been consistently identified as a risk factor for hyper-
tension in other populations. For example, a study in Cuba16
reported a similar prevalence of hypertension in populations
classified as White or Afro-descendants, while in a study in
Puerto Rico, Afro-descendants had higher prevalence of hy-
pertension compared with Whites.17 In Brazil, a study using
self-report ethnicity observed a higher prevalence among
the Afro-descendants, followed by Whites and Mixed race,18
a similar pattern to the present study. A  recent report in
American adults showed that adult Afro-descendants have
a higher prevalence of hypertension (45.3% versus 31.4%,
adjusted OR: 2.24 [95% CI: 1.97–2.56]), while Hispanics
have a similar prevalence as Whites.19 Taken together, these
results suggest that other factors may mediate hypertension
risk in different ethnic groups.
The presence of hypertension in the Colombian popula-
tion was associated with known risk factors such as older
age, increased BMI, increased WC, and greater WHR, with
WHR showing a stronger association than BMI in all ethnic
groups.9 Low education was associated with hypertension in
all ethnic groups, and particularly in Afro-descendants in
whom it was the modifiable risk factor with the strongest as-
sociation. Notably, 70% of Afro-descendants had a low level
of education compared with 52% of Whites. While 26.6% of
Whites attended university, only 7.8% of Afro-descendants
did so. Afro-descendants represent 10.6% of the popula-
tion and have a lower socioeconomic level compared with
the remainder of the population. According to data from
the Colombian National Survey (DANE 2019), the multi-
dimensional poverty index for the Afro-descendant pop-
ulation was 30.6% compared with 19.6% for the whole
population.20 A  higher poverty index is associated with
American Journal of Hypertension 5
 Table 2. Association between hypertension, sociodemographic factors, and anthropometric measures according to ethnicity
6

Lopez-Lopez et al.
American Journal of Hypertension

Univariate* Multivariate*

White Mestizo Afro-descendant White Mestizo Afro-descendant

PR (95% CI) PR (95% CI) PR (95% CI) PR (95% CI) PR (95% CI) PR (95% CI)

Sex
Female Reference Reference Reference Reference Reference Reference
Male 1.02 (0.83 to 1.26) 0.98 (0.88 to 1.08) 0.93 (0.75 to 1.16) 0.99 (0.81 to 1.2) 0.98 (0.89 to 1.07) 0.92 (0.75 to 1.13)
Age
<50 years Reference Reference Reference Reference Reference Reference
≥50 years 1.98 (1.57 to 2.48) 2.36 (2.12 to 2.64) 1.99 (1.6 to 2.47) 1.91 (1.52 to 2.4) 2.17 (1.94 to 2.43) 1.84 (1.46 to 2.32)
BMI (kg/m2)
F: (12.9–24.5); M: (16.4–23.2) Reference Reference Reference Reference Reference Reference
F: (24.6–28.3); M: (23.3 -26.4) 1.27 (0.96 to 1.68) 1.32 (1.15 to 1.51) 1.27 (0.98 to 1.65) 1.03 (0.78 to 1.37) 1.17 (1.01 to 1.35) 1.09 (0.8 to 1.48)
F: (28.4–76.8); M: (26.5–66.6) 1.69 (1.31 to 2.18) 1.67 (1.47 to 1.89) 1.35 (1.05 to 1.74) 1.34 (0.98 to 1.82) 1.28 (1.08 to 1.51) 1.03 (0.7 to 1.51)
WC (cm)
F: (47.1–79.5); M: (45–83.0) Reference Reference Reference Reference Reference Reference
F: (79.6–89.0); M: (83.1–92.0) 1.84 (1.38 to 2.45) 1.28 (1.12 to 1.47) 1.43 (1.07 to 1.92) 1.49 (1.06 to 2.08) 1.08 (0.92 to 1.26) 1.25 (0.87 to 1.8)
F: (89.1–150.7); M: (92.1–138) 1.93 (1.45 to 2.55) 1.82 (1.6 to 2.06) 1.56 (1.19 to 2.05) 1.34 (0.9 to 2.0) 1.3 (1.07 to 1.56) 1.27 (0.8 to 2.03)
WHR
F: (0.46–0.83); M: (0.55–0.91) Reference Reference Reference Reference Reference Reference
F: (0.84–0.88); M: (0.92–0.96) 1.54 (1.18 to 2.01) 1.16 (1.01 to 1.32) 1.32 (1.04 to 1.68) 1.1 (0.82 to 1.48) 0.99 (0.87 to 1.14) 1.23 (0.93 to 1.62)
F: (0.89–2.22); M: (0.97–2.38) 1.58 (1.22 to 2.05) 1.5 (1.33 to 1.7) 1.33 (1.02 to 1.72) 1.07 (0.78 to 1.45) 1.01 (0.87 to 1.16) 0.9 (0.66 to 1.24)
HGW
F: (0.40–1.45); M: (0.57–1.61) Reference Reference Reference Reference Reference Reference
F: (0.31–0.39); M: (0.45–0.56) 1.08 (0.83 to 1.4) 1.1 (0.97 to 1.26) 1.37 (1.04 to 1.8) 0.86 (0.67 to 1.09) 0.91 (0.8 to 1.03) 1.12 (0.86 to 1.47)
F: (0.05–0.30); M: (0.11–0.44) 1.25 (0.98 to 1.6) 1.5 (1.33 to 1.69) 1.55 (1.19 to 2.0) 0.83 (0.65 to 1.07) 1.01 (0.89 to 1.14) 1.18 (0.89 to 1.57)
Education level
High Reference Reference Reference Reference Reference Reference
Middle 1.45 (1.07 to 1.96) 1.0 (0.81 to 1.25) 1.16 (0.64 to 2.09) 1.57 (1.16 to 2.11) 1.11 (0.9 to 1.36) 1.44 (0.85 to 2.41)
Low 1.34 (1.02 to 1.74) 1.31 (1.09 to 1.57) 1.81 (1.06 to 3.09) 1.62 (1.21 to 2.17) 1.46 (1.21 to 1.75) 2.14 (1.3 to 3.53)
Location
Urban Reference Reference Reference Reference Reference Reference
Rural 0.8 (0.64 to 0.99) 0.89 (0.8 to 0.98) 0.92 (0.73 to 1.15) 0.95 (0.74 to 1.23) 1.01 (0.9 to 1.13) 0.84 (0.66 to 1.07)

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 Ethnic Differences in the Prevalence of Hypertension in Colombia

higher unemployment, informal work, lower access to the

CI were adjusted by age, location, income, home cooking with solid fuels, body mass index, waist circumference, waist-to-hip ratio and handgrip adjusted by bodyweight. Bold values are
statistically significant. Abbreviations: BMI, body mass index; WC, waist circumference, WHR, waist-to-hip ratio; HGW, hand grip strength adjusted by weight; F , female; M, male; PR,
*Prevalence ratios and 95% CI from the univariate and multivariate using Poisson regression models with robust standard errors. In multivariate analysis prevalence ratios and 95%
health system a lower educational level, and a higher edu-

0.87 (0.78 to 0.97)

0.95 (0.72 to 1.26)
Afro-descendant

PR (95% CI) cational gap. Differences in educational level can be an ac-

Reference

Reference
curate indicator of social inequality21 and as we previously
reported, social inequality is an important risk factor for

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hypertension.9 Therefore, the higher prevalence of hyper-
tension in Colombia’s Afro-descendant population might be
explained by social inequality reflected in their lower mean
educational level and use of solid fuels in cooking. The me-
diation analysis showed that hypertension is associated with
0.84 (0.75 to 0.94)

0.85 (0.58 to 1.24) ethnicity, and that this association is mediated by education
Multivariate*

PR (95% CI)

Reference

Reference
Mestizo

level adjusted by socioeconomic factors such as coal cooking

and income, sex, and age. Supporting this view, we found
that the previously described22 association between low
handgrip strength and hypertension, was evident in Afro-
descendant and Mestizos but not in Whites, an ethnicity
with higher educational level and socioeconomic status.
This suggests that the ethnic differences in the association
0.93 (0.82 to 1.05)
1.0 (0.79 to 1.27)

between HGS and hypertension may also be related to social

PR (95% CI)

Reference

Reference

inequality. Few studies have examined ethnic and socioeco-

White

nomic differences in handgrip strength and its association

with cardiovascular risk factors.23–26 In British adults, Ntuk
et  al.27 reported ethnic differences in the association be-
tween HGS and the risk of diabetes, observing similar mean
HGS in Afro-descendants as Whites, but a higher attribut-
able risk for diabetes associated with low HGS in the Afro-
0.95 (0.74 to 1.22)

0.6 (0.41 to 0.86)

Afro-descendant

descendants males. In a cross-sectional study comparing

PR (95% CI)

Reference

Reference

anthropometric and cardiometabolic risk factors in Chilean

schoolchildren from 2 different ethnicities (Native Andean
Mapuches and White European descendants), Mapuche
children had higher blood pressure, lower adiposity levels
and lower levels of HGS,28 results that suggest that the inter-
action between adiposity, muscle strength and blood pres-
sure may also vary between ethnic groups.11
0.87 (0.79 to 0.97)

0.76 (0.53 to 1.1)

In the present study, we did not observe ethnic differences

PR (95% CI)
Univariate*

Reference

Reference

in food intake or in the nutritional parameters analyzed. The

Mestizo

REGARDS cohort29 that included 30,239 participants with a

9-year follow-up found that Afro-descendants had a greater
incidence of hypertension, which was partially explained by
a higher salt consumption, a higher Na/K intake, and higher
processed food consumption. This discrepancy may be related
to differences between the REGARDS study population and
0.87 (0.78 to 0.97)
0.94 (0.77 to 1.14)

our population in the amount and quality of food consumption.

PR (95% CI)

Reference

Reference

Our study has some limitations. The cross-sectional na-

White

prevalence ratio; 95% CI, 95% confidence interval.

ture of our study prevents us from establishing causality in

the associations we observed. Moreover, 65% of the included
population were women, limiting the representativeness of
the sample. However, we identified ethnic differences in the
association between specific risk factors and the prevalence
of hypertension y new information which may guide the de-
velopment of priorities within programs aimed at reducing
the prevalence of hypertension. In addition, the mediation
analysis showed that education level plays a direct role in the
differences in the prevalence of hypertension between ethnic
Table 2. Continued

Solid fuel cooking

groups. Educational level has been demonstrated as a reliable

marker of socioeconomic status and social inequality, better
≥350 USD
<350 USD

than self-reported income level.20 Therefore, addressing so-

cial inequities and increasing access and quality to education
Income

Yes
No

in low- and middle-income countries like Colombia is crit-

ical to improve population health status.

American Journal of Hypertension 7

Lopez-Lopez et al.

Table 3. Association between education level and hypertension

Female White Female Mestizo Female Afro-descendant

PR (95% CI) PR (95% CI) PR (95% CI)

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Education level

High Reference
Middle 1.53 (1.03 to 2.26) 1.13 (0.85 to 1.49) 1.87 (0.94 to 3.72)
Low 1.49 (1.03 to 2.14) 1.5 (1.16 to 1.93) 2.82 (1.44 to 5.53)
Education level Male White Male Mestizo Male Afro-descendant
PR (95% CI) PR (95% CI) PR (95% CI)
High Reference
Middle 1.76 (1.14 to 2.74) 1.06 (0.78 to 1.45) 0.82 (0.34 to 1.95)
Low 1.73 (1.03 to 2.91) 1.35 (1.03 to 1.76) 1.33 (0.6 to 2.94)

The table shows the association obtained from Poisson regression models with robust standard errors separately by sex and self-recognized
ethnicity. PRs and 95% CI were adjusted by age, location, income, home cooking with solid fuels, body mass index, waist circumference, waist-
to-hip ratio and handgrip adjusted by bodyweight. Bold values are statistically significant. Abbreviations: PR, prevalence ratio; 95% CI, 95%
confidence interval.

Table 4. Association between self-recognized ethnicity and
hypertension mediated by education level.
Proportion of the mediator effect
Model estimate (95% CI)
Carlos Cure; Aristides Sotomayor; Alvaro Rico; Eric
Hernandez-Triana; Myriam Duran; Fresia Cotes by the
help with the development of study in the Departments of
p-value
Colombia.

Model 1 0.038 (−0.019 to 0.144) 0.150

Model 2 0.176 (0.059 to 0.714)
Model 3 0.192 (0.063 to 0.724)
Model 4 0.135 (0.046 to 0.359)
Model 5 −0.022 (−0.135 to 0.081)
Model 6 −0.054 (−0.232 to 0.003)
Bold values are statistically significant.
Mediation analysis adjusted for selected covariates.
Model 1: Response variable: hypertension; direct effect: ethnicity;
the mediator effect: education.
Model 2: Model 1 plus coal cooking as covariate.
Model 3: Model 2 plus sex as covariate.
Model 4: Model 3 plus age as covariate.
Model 5: Model 4 plus income as covariate.
Model 6: Model 1 plus sex, age and income as covariates.
FUNDING
The main PURE study is funded by the Population
Health Research Institute, the Canadian Institutes of Health
Research and the Heart and Stroke Foundation of Ontario.
In Colombia, the study had a partial financial support of
COLCIENCIAS Grants 6566-04-18062 and 6517-777-58228.
ACKNOWLEDGMENTS
To Paul A  Camacho; Gregorio Sanchez-Vallejo; Edgar
Arcos; Claudia Narvaez; Henry Garcia; Dora I.  Molina;
0.014 DISCLOSURE
0.018
The authors declared no conflict of interest.
<0.001
0.798
0.062
REFERENCES
1. Forouzanfar  MH, Liu  P, Roth  GA, Ng  M, Biryukov  S, Marczak  L,
Alexander  L, Estep  K, Abate  KH, Akinyemiju  TF, Ali  R, Alvis-
Guzman N, Azzopardi P, Banerjee A, Bärnighausen T, Basu A, Bekele T,
Bennett  DA, Biadgilign  S, Catalá-López  F, Feigin  VL, Fernandes  JC,
Fischer  F, Gebru  AA, Gona  P, Gupta  R, Hankey  GH, Jonas  JB,
Judd  SE, Khang  Y-H, Khosravi  A, Kim  YJ, Kimokoti  RW, Kokubo  Y,
Kolte D, Lopez A, Lotufo PA, Malekzadeh R, Melaku YA, Mensah GA,
Misganaw A, Mokdad AH, Moran AE, Nawaz H, Neal B, Ngalesoni FN,
Ohkubo T, Pourmalek F, Rafay A, Rai RK, Rojas-Rueda D, Sampson UK,
Santos  IS, Sawhney  M, Schutte  AE, Sepanlou  SG, Shifa  GT, Shiue  I,
Tedla BA, Thrift AG, Tonelli M, Truelsen T, Tsilimparis N, Ukwaja KN,
Uthman  OA, Vasankari  T, Venketasubramanian  N, Vlassov  VV,
Vos T, Westerman R, Yan LL, Yano Y, Yonemoto N, El Sayed Zaki M,
Murray CJL. Global burden of hypertension and systolic blood pressure
of at least 110 to 115 mm Hg, 1990-2015. JAMA 2017; 317:165–182.
2. Chow  CK, Teo  KK, Rangarajan  S, Islam  S, Gupta  R, Avezum  A,
Bahonar A, Chifamba J, Dagenais G, Diaz R, Kazmi K, Lanas F, Wei L,
Lopez-Jaramillo  P, Fanghong  L, Ismail  NH, Puoane  T, Rosengren  A,
Szuba  A, Temizhan  A, Wielgosz  A, Yusuf  R, Yusufali  A, McKee  M,
Liu L, Mony P, Yusuf S. Prevalence, awareness, treatment, and control
of hypertension in rural and urban communities in high-, middle-, and
low-income countries. JAMA 2013; 310:959–968.
3. Dorans KS, Mills KT, Liu Y, He J. Trends in prevalence and control of
hypertension according to the 2017 American College of Cardiology/
American Heart Association (ACC/AHA) guideline. J Am Heart Assoc
2018; 7:e008888.
4. Whelton  PK, Einhorn  PT, Muntner  P, Appel  LJ, Cushman  WC,
Diez  Roux  AV, Ferdinand  KC, Rahman  M, Taylor  HA, Ard  J,
Arnett DK, Carter BL, Davis BR, Freedman BI, Cooper LA, Cooper R,

8 American Journal of Hypertension


Desvigne-Nickens  P, Gavini  N, Go  AS, Hyman  DJ, Kimmel  PL,
Margolis  KL, Miller 3rd ER, Mills  KT, Mensah  GA, Navar  AM,
Ogedegbe G, Rakotz MK, Thomas G, Tobin JN, Wrigth JT, Yoon SSS,
Cutler JA. Research needs to improve hypertension treatment and con-
trol in African Americans. Hypertension 2016; 68:1066–1072.
5. Yoon  SS, Gu  Q, Nwankwo  T, Wright  JD, Hong  Y, Burt  V. Trends in
blood pressure among adults with hypertension: United States, 2003 to
2012. Hypertension 2015; 65:54–61.
6. Munoz  AM, Velasquez  CM, Bedoya  G. Cardio-metabolic parameters
are associated with genetic admixture estimates in a pediatric popula-
tion from Colombia. BMC Genet 2016;17(1):93.
7. DANE. Resultados del Censo Nacional de Población y Vivienda
2018. 2019. https://www.dane.gov.co/index.php/estadisticas-por-tema/
demografia-y-poblacion/censo-nacional-de-poblacion-y-vivenda-
2018/cuantos-somos.
8. Teo K, Chow CK, Vaz M, Rangarajan S, Yusuf S, PURE Investigators-
Writing Group. The Prospective Urban Rural Epidemiology (PURE)
study: examining the impact of societal influences on chronic
noncommunicable diseases in low-, middle-, and high-income coun-
tries. Am Heart J 2009; 158:1–7.e1.
9. Camacho  PA, Gomez-Arbelaez  D, Molina  DI, Sanchez  G, Arcos  E,
Narvaez  C, Garcia  H, Perez  M, Hernandez  EA, Duran  M, Cure  C,
Sotomayor A, Rico A, David TM, Cohen DD, Rangarajan S, Yusuf S,
Lopez-Jaramillo  P. Social disparities explain differences in hyperten-
sion prevalence, detection and control in Colombia. J Hypertens 2016;
34:2344–2352.
10. Dehghan  M, Lopez-Jaramillo  P, Duenas  R, Anaya  LL, Garcia  RG,
Zhang X, Islam S, Merchant AT. Development and validation of a quan-
titative food frequency questionnaire among rural- and urban-dwelling
adults in Colombia. J Nutr Educ Behav 2012; 44:609–613.
11. Leong  DP, Teo  KK, Rangarajan  S, Lopez-Jaramillo  P, Avezum  A,
Orlandini  A, Seron  P, Ahmed  SH, Rosengren  A, Kelishadi  R,
Rahman  O, Swaminathan  S, Iqbal  R, Gupta  R, Lear  SA, Oguz  A,
Yusoff K, Zatonska K, Chifamba J, Igumbor E, Mohan V, Anjani RM,
Gu H, Li W, Yusuf S. Prognostic value of grip strength: findings from
the Prospective Urban Rural Epidemiology (PURE) study. Lancet 2015;
386:266–73.
12. Mente  A, O’Donnell  MJ, Dagenais  G, Wielgosz  A, Lear  SA,
McQueen MJ Jiang Y, Xingyu W, Jian B, Calik KBT, Akalin AA, Mony P,
Devanath  A, Yusufali  AH, Lopez-Jaramillo  P, Avezum  A, Yusoff  K,
Rosengren  A, Kruger  L, Orlandini  A, Rangarajan  S, Teo  K, Yusuf  S.
Validation and comparison of three formulae to estimate sodium and
potassium excretion from a single morning fasting urine compared to
24-h measures in 11 countries. J Hypertens 2014; 32:1005–1014.
13. Baron  RM, Kenny  DA. The moderator-mediator variable distinction
in social psychological research: conceptual, strategic, and statistical
considerations. J Pers Soc Psychol 1986; 51:1173–1182.
14. Barrera L, Gomez F, Ortega-Lenis D, Ojeda JC, Mendez F. Prevalence,
awareness, treatment and control of high blood pressure in the elderly
according to the ethnic group. Colombian survey. Colomb Med (Cali)
2019; 50:115–127.
15. Center for Disease Control and Prevention. Hypertension Among
Adults Aged 20 and Over, by Selected Characteristics: United States,
Selected Years 1988–1994 Through 2013–2016. 2018; (3): 1–2 pp.
https://www.cdc.gov/nchs/data/hus/2018/022.pdf
Ethnic Differences in the Prevalence of Hypertension in Colombia
16. Ordúñez P, Kaufman JS, Benet M, Morejon A, Silva LC, Shoham DA,
Cooper  RS. Blacks and whites in the Cuba have equal prevalence of
hypertension: confirmation from a new population survey. BMC Public
Health. 2013;13:169.
17. Gravlee CC, Dressler WW, Bernard HR. Skin color, social classification,
and blood pressure in southeastern Puerto Rico. Am J Public Health.
Downloaded from https://academic.oup.com/ajh/advance-article/doi/10.1093/ajh/hpac051/6569200 by Pontificia Universidad Javeriana user on 27 May 2022
2005;95(12):2191–7.
18. Juliao NA, de Souza A, Guimaraes RRM. Trends in the prevalence of
systemic arterial hypertension and health care service use in Brazil over
a decade (2008–2019). Cien Saude Colet. 2021;26(9):4007–4019.
19. Aggarwal  R, Chiu  N, Moran  AE, Raber  I, Shen  C, Yeh  R, Kazi  DS.
Racial/ethnic disparities in hypertension prevalence, awareness, treat-
ment, and control in the United States, 2013 to 2018. Hypertension
2021; 78:1719–1726.
20. DANE. Población negra, afrocolombiana, raizal y palenquera:
resultados del censo nacional de población y vivienda 2018. 2019;
(69). https://www.dane.gov.co/files/investigaciones/boletines/grupos-
etnicos/presentacion-grupos-etnicos-poblacion-NARP-2019.pdf.
21. Gamboa L, Londoño E. Assessing Educational Unfair Inequalities at a
Regional Level in Colombia. Lecturas Econ 2015;23:97–133.
22. Mainous AG, 3rd, Tanner RJ, Anton SD, Jo A. Grip strength as a marker
of hypertension and diabetes in healthy weight adults. Am J Prev Med
2015;49(6):850–858.
23. Thorpe  RJ, Simonsick  E, Zonderman  A, Evans  MK. Association be-
tween race, household income and grip strength in middle- and older-
aged adults. Ethn Dis 2016; 26:493–500.
24. Leong  DP, Teo  KK, Rangarajan  S, Kutty  VR, Lanas  F, Hui  C,
Quanyong  X, Zhenzhen  Q, Jinhua  T, Noorhassim  I, AlHabib  KF,
Moss SJ, Rosengren A, Akalin AA, Rahman O, Chifamba J, Orlandini A,
Kumar R, Yeates K, Gupta R, Yusufali A, Dans A, Avezum A, Lopez-
Jaramillo P, Poirier P, Heidari H, Zatonska K, Iqbal R, Khatib R, Yusuf S.
Reference ranges of handgrip strength from 125,462 healthy adults in
21 countries: a prospective urban rural epidemiologic (PURE) study. J
Cachexia Sarcopenia Muscle 2016; 7:535–546.
25. Otero  J, Cohen  DD, Herrera  VM, Camacho  PA, Bernal  O, Lopez-
Jaramillo  P. Sociodemographic factors related to handgrip strength
in children and adolescents in a middle-income country: the SALUS
study. Am J Hum Biol 2017; 29:1–10.
26. Griffin  FR, Mode  NA, Ejiogu  N, Zonderman  AB, Evans  MK. Frailty
in a racially and socioeconomically diverse sample of middle-aged
Americans in Baltimore. PLoS One 2018; 13:e0195637.
27. Ntuk  UE, Celis-Morales  CA, Mackay  DF, Sattar  N, Pell  JP, Gill  JMR.
Association between grip strength and diabetes prevalence in black,
South-Asian, and white European ethnic groups: a cross-sectional anal-
ysis of 418 656 participants in the UK Biobank study. Diabet Med 2017;
34:1120–1128.
28. Alvarez  C, Flores-Opazo  M, Mancilla  R, Martinez-Salazar  C,
Mangiamarchi  P, Sade-Calles  F, Ramírez-Campillo  R. Gender
differences in blood pressure and body composition in schoolchildren
ascendants from Amerindian and European. Ethn Health 2019; 1:12.
29. Howard G, Cushman M, Moy CS, Oparil S, Muntner P, Lackland DT,
Manly JJ, Flaherty ML, Judd SE, Wadley VG, Long DL, Howard VJ.
Association of clinical and social factors with excess hyperten-
sion risk in black compared with white US Adults. JAMA 2018;
320:1338–1348.
American Journal of Hypertension 9