Obesity and hypertension among collegeeducated black women in the United States

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1 Journal of Human Hypertension (1999) 13, Stockton Press. All rights reserved /99 $ ORIGINAL ARTICLE Obesity and hypertension among collegeeducated black women in the United States L Rosenberg 1, JR Palmer 1, LL Adams-Campbell 2 and RS Rao 1 1 Slone Epidemiology Unit, Boston University School of Medicine, Brookline, MA; 2 Howard University Cancer Center, Howard University College of Medicine, Washington, DC, USA It is established that obesity is an important risk factor for hypertension, but there is little information on this relationship among highly educated black women. We assessed the relationship of body mass index (weight (kg)/height 2 (m)) to prevalent hypertension among US black women who had completed college, and among less educated women as well. The data were collected in 1995 in the Black Women s Health Study: African American women aged 21 to 69 years enrolled by completing mailed health questionnaires; 44% of the participants had completed college. We compared the 9394 participants who reported a diagnosis of hypertension treated with a diuretic or antihypertensive drug (cases) with 9259 participants of similar ages who did not have hypertension (controls). Multivariate odds ratios were estimated by logistic regression. The odds ratio for treated hypertension increased with increasing body mass index at every educational level. Among college-educated women, the odds ratio for hypertension was 2.7 for overweight women (index ) and 4.9 for severely overweight women (index 32.3), relative to women with a body mass index The prevalences of obesity and hypertension were high among the college-educated women, although not as high as among women with fewer years of education. About a quarter of the difference in the prevalence of hypertension across educational levels was explained by the difference in the proportions who were overweight or severely overweight. These results document a high prevalence of obesity and hypertension, and a strong association of obesity with hypertension, among highly educated US black women. Keywords: blacks; body mass; hypertension; obesity; women Introduction The overall age-adjusted mortality rate in African- American women exceeds that in US white women by 50%, and coronary heart disease and cerebrovascular disease are among the leading causes of death. 1 3 Obesity, an important risk factor for cardiovascular disease, 4 6 occurs more commonly among African-American women, and hypertension, another important risk factor, also is more common among black women. 6 8 In this report, we assess the relationship of obesity to the occurrence of hypertension in US black women, using data from the Black Women s Health Study. We focused on women who had completed college or higher levels of education, a subgroup for which data from previous studies are sparse. 7 Materials and methods Data collection In 1995, US black women aged 21 to 69 years were enrolled in the Black Women s Health Study Correspondence: Dr Lynn Rosenberg, Slone Epidemiology Unit, 1371 Beacon Street, Brookline, MA 02446, USA Received 29 June 1998; revised 5 October 1998; accepted 4 December 1998 through postal questionnaires. The questionnaires were sent to subscribers to Essence magazine (a women s magazine whose readership consists almost entirely of black women), members of selected black women s professional organizations, and friends and relatives of early respondents. The median age of respondents was 38, and 44% had completed college. The women were from all parts of the US, with over 80% residing in California, Georgia, Illinois, Indiana, Louisiana, Maryland, Massachusetts, Michigan, New Jersey, New York, South Carolina, Virginia, and the District of Columbia. The data obtained included information on demographic factors, medical history, current weight, height, and weight at age 18. The women were asked if they had any of a list of medical conditions, including high blood pressure, and whether they used a diuretic or antihypertensive drug. Ninety-six percent of participants reported having had their blood pressure checked within the previous 3 years. The present report is based on the data on hypertension, height, weight and other factors collected with this baseline questionnaire. As a check on the reproducibility of self-reports of height and weight, we analysed the responses of 182 participants who filled out duplicate questionnaires, on average 5 months after the first one. The mean values reported on the first and second

2 238 questionnaires were: current weight, 175 lb. and 173 lb.; height, 66 in and 65 in.; weight at age 18, 131 lb. and 131 lb. The medians were: current weight, 165 lb. and 164 lb.; height, 66 in. and 66 in.; weight at age 18, 131 lb. and 131 lb. The correlation coefficients for the reporting of these variables on the two questionnaires ranged from 0.90 to 0.94 and all were statistically significant (P 0.001). Cases and controls The case group (drug-treated hypertension) consisted of 9394 women who reported having been diagnosed with high blood pressure and were currently using a diuretic or antihypertensive drug for high blood pressure. This definition was chosen because it identified women with unequivocal hypertension. Women who reported the diagnosis of high blood pressure but who were not using a diuretic or antihypertensive drug were not included as cases. The cases were frequency-matched on 5-year age group with 9259 controls, who were women who had not reported a diagnosis of high blood pressure or use of diuretic or antihypertensive drugs. Women who reported a diagnosis of high blood pressure but who were not using a diuretic or antihypertensive drug were not included as controls. For women under age 60, the control to case ratio was 1:1; for women aged 60 69, there were fewer controls (1348) than cases (1482). Data analysis Odds ratios for the association of prevalent hypertension with body mass index (BMI: wt(kg)/ht 2 (m)) were estimated from unconditional logistic regression equations 9 using the SAS GENMOD procedure; indicator terms were used for body mass index, 5-year age group, geographic region, education, cigarette smoking, and alcohol consumption. To test for trends, ordinal terms were included in the regression. Analysis of variance was used to test for differences in mean values, by the SAS GLM procedure. Results Table 1 gives data on BMI among the 9394 cases and 9259 controls. The odds ratio for hypertension rose Table 1 Body mass index (BMI) in relation to prevalent drugtreated hypertension among 9394 cases and 9259 controls* BMI (kg/m 2 ) Cases Controls Odds ratio (95% No. No. confidence interval) (1.0) ( ) ( ) ( ) ( ) *Cases and controls with unknown values for BMI are excluded from the table. From logistic regression with control for age, geographic region, years of education, cigarette smoking, and alcohol consumption. Reference category. as BMI increased (P for trend 0.001). For women were overweight but not severely overweight according to the definition of the National Center for Health Statistics 5 (BMI ) compared to women with BMI 22.8, the odds ratio was 2.6 (95% CI ). For those who were severely overweight (BMI 32.3) the odds ratio was 4.7 (95% CI ). Table 2 gives data on BMI and hypertension according to the number of years of education completed, 12, 13 15, and 16. In each category of years of education, the odds ratio for hypertension increased as BMI increased; the trend in each category was statistically significant (P 0.001). Among women who had completed college ( 16 years of education), the odds ratio was 2.7 (95% CI ) for overweight women and 4.9 (95% CI ) for severely overweight women, relative to women with BMI Table 3 provides data on current BMI and the change in BMI since age 18 among the 9259 controls, according to age and educational attainment. Current BMI was inversely related to the level of education (P 0.001). The proportion of women who were overweight or severely overweight (BMI 27.3) increased with age, and decreased with educational level. Among women who had completed college, the proportion increased from 33.5% at years old to 45.4% at 50 69, compared with 41.8% and 50.5% respectively, among women who had completed 12 or fewer years of education. At each age the weight gain since age 18 was smallest for those in the highest category of education (P 0.001). Table 4 gives the age-specific prevalence of drugtreated hypertension according to years of education completed among the participants in the Black Women s Health Study. Among women who had completed college, the prevalence increased from 1.3% at age to 45.0% at age Within each age category, the prevalence of hypertension was inversely related to years of education (P for trend 0.001). Table 5 shows the prevalence of hypertension among the three education categories after adjustment to the age distribution of all Black Women s Health Study participants. The age-adjusted prevalence among women with years of education was 14% lower than that among women with 12 or fewer years of education, while that among collegeeducated women was 27% lower (P for trend 0.001). After adjustment for the distribution of BMI, the difference was reduced to 11% for women with years of education and 20% for collegeeducated women; however, the trend for the prevalence of treated hypertension to increase as level of education decreased was still statistically significant (P 0.001). Thus, 21% of the difference in the prevalence of hypertension between women with 12 years of education and those with years (ie, 3/14), and 26% of the difference between women with 12 years and those with 16 years of education (ie, 7/27), was explained by the difference in the distribution of BMI.

3 Table 2 Body mass index (BMI) in relation to prevalent drug-treated hypertension among 9394 cases and 9259 controls, according to years of education completed* 239 Years of Total BMI (kg/m 2 ) education no. completed Cases Controls Odds ratio (1.0) 1.3 ( ) 1.7 ( ) 2.2 ( ) 4.3 ( ) Cases Controls Odds ratio (1.0) 1.5 ( ) 1.8 ( ) 2.8 ( ) 4.7 ( ) 16 Cases Controls Odds ratio (1.0) 1.3 ( ) 2.0 ( ) 2.7 ( ) 4.9 ( ) *Cases and controls with unknown values for BMI or years of education are excluded from the table. From logistic regression with control for age, geographic region, cigarette smoking, and alcohol consumption. Reference category. Table 3 Current body mass index (BMI), percent with current BMI 27.3, and change in BMI since age 18 among 9259 controls, according to age and years of education completed* Years of Age (yr) education completed Current BMI (mean) Current BMI 27.3 (%) Change in BMI since age Current BMI (mean) Current BMI 27.3 (%) Change in BMI since age Current BMI (mean) Current BMI 27.3 (%) Change in BMI since age *BMI = wt(kg)/ht 2 (m); women with unknown values for BMI or years of education are excluded from the table. Table 4 Prevalence of drug-treated hypertension among Black Women s Health Study participants, according to age and years of education completed* Age (yr) Years of education completed No. with No. with No. with hypertension hypertension hypertension (%) (%) (%) (2.8) 96 (1.6) 81 (1.3) (8.8) 598 (7.3) 554 (5.8) (24.5) 1222 (20.2) 1292 (16.5) (40.7) 865 (37.8) 1064 (33.8) (52.5) 357 (49.1) 557 (45.0) *Women with unknown values for years of education completed are not included in the table. Table 5 Prevalence of drug-treated hypertension among Black Women s Health Study participants according to years of education completed, adjusted for age and body mass index (BMI)* Years of education completed Prevalence adjusted for age* 18.0% 15.5% 13.2% Relative prevalence Prevalence adjusted for age 17.2% 15.3% 13.7% and BMI* Relative prevalence *Adjusted to distribution of all Black Women s Health Study participants. Prevalence relative to that of women with 12 years of education. Discussion Associations between obesity and incident and prevalent hypertension in women have been well documented. 7,8,10,11 The present results from the Black Women s Health Study provide further evidence of the important role of overweight as a risk factor for hypertension in black women. The study includes a high representation of well-educated women, with 44% having completed college as against about 14% of African American women of the same ages in the total US population. 12 A strong relationship between high BMI and increased risk of hypertension was evident at every level of educational attainment. Among college-educated women, the odds ratio was increased almost threefold among women who were overweight (BMI ), and almost five-fold among those who were severely overweight (BMI 32.3). Obesity is common in US black women. 4 6 In the present study, 33.5% of college-educated women under age 40 who did not have hypertension were overweight or severely overweight, and the proportion increased to 45.4% among those aged years. The comparable proportions among women with 12 or fewer years of education were even

4 240 greater, 41.8% and 50.5%, respectively. Only a small proportion of the Black Women s Health Study participants were overweight at age 18, based on their self-reports. Thus, it appears that large weight gains occurred later, in accord with data from other studies. 4,5 The weight gains among women in the present study were smaller among college-educated than among less educated women. A high prevalence of hypertension has been documented in African-American women. 6 8 In the present study, while the prevalence of treated hypertension was lower among college-educated women than among less educated women, it was nevertheless high among college-educated women, reaching 45.0% at ages Adjustment for BMI appeared to explain about a quarter of the difference in the prevalence of hypertension across categories of education. Other important factors that may have contributed to the difference across education include differences in patterns of dietary intake and exercise. Our findings of an inverse association of education with both obesity and hypertension were expected, and are in agreement with studies of white populations. Perhaps less expected was the finding of a high prevalence of obesity and hypertension among the most educated women, those with a college education. This finding underscores the complexity of factors that influence individual decisions about diet and exercise. It has been suggested that there may be special cultural constraints that influence the success of behavioural change programmes among black women, among them ambivalence about the health benefits of weight reduction and dietary change, a relatively tolerant attitude towards moderate obesity, positive values placed on certain high-fat, high-sodium foods, and a failure to identify with the heart healthy movement. 6 Dietary and physical activity intervention programmes may be more effective if designed for particular cultural frameworks. With respect to self-report of current weight and height, there is evidence that they are reported accurately, 4,11,13 15 although there is a tendency for women to underestimate their weights. Inaccuracies, if non-differential, would have weakened the association of BMI with hypertension in the present study. Weight at age 18 has not been assessed in validation studies. However, elderly black persons in the Charleston Heart Study reported their weight 28 years previously with good precision, and the accuracy was greater the younger and more educated the person. 14 While weight and height were not validated in the present study, a subgroup of women had completed two questionnaires. The reproducibility of reporting was found to be high in that subgroup. To reduce misclassification, women were classified as having hypertension in the present study only if they had received a diuretic or antihypertensive drug for the condition. It is unlikely that an appreciable proportion of participants had undiagnosed hypertension, because virtually all reported having had their blood pressure checked in the previous 3 years. It was possible that women enrolled selectively in the Black Women s Health Study according to certain characteristics. For example, women with serious health problems may have been more likely (due to greater interest) or less likely (due to their poor health) to participate. Selective enrolment would affect cross-sectional analyses only if women had enrolled selectively based on more than one of the characteristics or conditions being studied. Thus, if obese women with hypertension had been more likely to complete and return the baseline questionnaire than non-obese women with hypertension, this would have distorted the relationship of obesity to hypertension. There is no obvious reason to think that this sort of selective enrolment would have occurred, or that it would have occurred differentially within categories of education. In conclusion, the present results document a high prevalence of obesity and of hypertension among college-educated black women, although lower than that among less educated women, and a strong association of obesity with hypertension at all educational levels. Acknowledgements This work was supported by NCI grant R01 CA We gratefully acknowledge the participation of the women in the Black Women s Health Study, the technical help of Delia Russell, Elizabeth Sylvestre, Juanita Hope, Yvette Cozier, Nurhayatti Prihartono, Ana DeMorais, and Alexei Kataenko, and the advice of the Black Women s Health Study Advisory Board. References 1 National Center for Health Statistics. Health, United States Hyattsville, MD: Public Health Service, Gillum RF. Cardiovascular disease in the United States: an epidemiologic overview. Cardiovasc Clin 1991; 21: Gillum RF. Coronary heart disease in black populations. I. Mortality and morbidity. Am Heart J 1982; 104: Kumanyika S. Obesity in black women. Epidemiol Rev 1987; 9: Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. Increasing prevalence of overweight among US adults. The National Health and Nutrition Examination Surveys, 1960 to JAMA 1994; 272: Kumanyika S, Adams-Campbell LL. Obesity, diet, and psychosocial factors contributing to cardiovascular disease in blacks. In: Saunders E, Brest A (eds). Cardiovascular Diseases in Blacks. Cardiovascular Clinic. F.A. Davis Co: Philadelphia, 1991, 21, pp Gillum RF. Epidemiology of hypertension in African- American women. Am Heart J 1996; 131: Cornoni-Huntley J, LaCroix AZ, Havlik RJ. Race and sex differentials in the impact of hypertension in the United States. The national Health and Nutrition Examination Survey. I. Epidemiologic Follow-up Study. Arch Intern Med 1989; 149: Schlesselman JJ. Case-control studies: Design, conduct, analysis. Oxford University Press: New York, Kumanyika SK. The association between obesity and

5 hypertension in blacks. Clin Cardiol 1989; 12 (Suppl 4): IV Manson JE et al. A prospective study of obesity and risk of coronary heart disease in women. N Engl J Med 1990; 322: Kominski R, Adams A. Educational attainment in the United States. March 1991 and 1990 Current population reports. Population characteristics. Series P-20, No US Dept Commerce, May Rowland ML. Reporting bias in height and weight data. Statistical Bulletin 1989; 70: Rowland ML. Self-reported weight and height. Am J Clin Nutr 1990; 52: Stevens J, Keil JE, Waid RL, Gazes PC. Accuracy of current, 4-year, and 28-year self-reported body weight in an elderly population. Am J Epidemiol 1990; 132:

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