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Higher blood pressure in middle-aged American adults with less education—role of multiple dietary factors: The INTERMAP Study

Journal of Human Hypertension volume 17, pages 655–664 (2003)Cite this article

Abstract

Extensive evidence exists that an inverse relation between education and blood pressure prevails in many adult populations, but little research has been carried out on reasons for this finding. A prior goal of the INTERMAP Study was to investigate this phenomenon further, and to assess the role of dietary factors in accounting for it. Of the 4680 men and women aged 40–59 years, from 17 diverse population samples in Japan, People's Republic of China, UK, and USA, a strong significant inverse education–BP relation was manifest particularly for the 2195 USA participants, independent of ethnicity. With participants stratified by years of education, and assessment of 100+ dietary variables from four 24-h dietary recalls and two 24-h urine collections/person, graded relationships were found between education and intake of many macro- and micronutrients, electrolytes, fibre, and body mass index (BMI). In multiple linear regression analyses with systolic BP (SBP) and diastolic BP (DBP) of individuals the dependent variables (controlled for ethnicity, other possible nondietary confounders), BMI markedly reduced size of education–BP relations, more so for women than for men. Several nutrients considered singly further decreased size of this association by ⩾10%: urinary 24-h Na and K excretion, Keys dietary lipid score, vegetable protein, fibre, vitamins C and B6, thiamin, riboflavin, folate, calcium, magnesium, and iron. Combinations of these dietary variables and BMI attenuated the education–SBP inverse coefficient by 54–58%, and the education–DBP inverse coefficient by 59–67%, with over half these effects attributable to specific nutrients (independent of BMI). As a result, the inverse education–BP coefficients ceased to be statistically significant. Multiple specific dietary factors together with body mass largely account for the more adverse BP levels of less educated than more educated Americans. Special efforts to improve eating patterns of less educated strata can contribute importantly to overcoming this and related health disparities in the population.

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Acknowledgements

The INTERMAP study has been supported by Grant 2-RO1-HL50490 from the US National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; by the Chicago Health Research Foundation; and by national agencies in Japan (the Ministry of Education, Science, Sports, and Culture, Grant-in-Aid for Scientific Research [A] No. 090357003) People's Republic of China, and the United Kingdom. It is a pleasure for us to express appreciation for fine contributions of many colleagues at INTERMAP research facilities in Belgium, Japan, PRC, UK, and USA; for a listing of these facilities and many of the co-workers at each of these centres, see Stamler et al.17

Author information

Author notes

  1. P Elmer: Formerly at: Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, MN, USA.

  2. D Labarthe: Formerly at: Department of Epidemiology, The University of Texas Houston Health Science Center, Houston, TX, USA.

Authors and Affiliations

  1. Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    J Stamler, AR Dyer, P Greenland, K Liu, A Moag-Stahlberg & L Van Horn

  2. Department of Epidemiology and Public Health, Faculty of Medicine, St Mary's Campus, Imperial College, London, UK

    P Elliott, Q Chan & C Robertson

  3. Welch Center for Prevention, Epidemiology, and Clinical Research, The Johns Hopkins Medical Institutions, Baltimore, MD, USA

    L Appel

  4. Nutrition Coordinating Center, University of Minnesota, Minneapolis, MN, USA

    M Buzzard & M Stevens

  5. Department of Preventive Medicine and Community Health, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA

    M Buzzard

  6. Department of Biostatistics, Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    B Dennis

  7. Kaiser Permanente, Center for Health Research, Portland, OR, USA

    P Elmer

  8. Department of Medicine, Division of Hypertension, University of Mississippi Medical Center, Jackson, MS, USA

    D Jones

  9. Central Laboratory, Akademisch Ziekenhuis St Rafael, Leuven, Belgium

    H Kesteloot

  10. Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA

    L Kuller

  11. Centers for Disease Control and Prevention, Atlanta, GA, USA

    D Labarthe

  12. Department of Epidemiology, The University of Texas Houston Health Science Center, Houston, TX, USA

    M Nichaman

  13. Department of Hygiene and Preventive Medicine, Iwate Medical University, Morioka, Japan

    A Okayama

  14. Department of Health Science, Shiga University of Medical Science, Otsu, Japan

    N Okuda & H Ueshima

  15. Honolulu Heart Program, University of Hawaii, Honolulu, HI, USA

    B Rodriguez

  16. Department of Epidemiology, Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing, People's Republic of China

    B Zhou

Authors
  1. J Stamler
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  2. P Elliott
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  3. L Appel
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  4. Q Chan
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  5. M Buzzard
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  6. B Dennis
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  7. AR Dyer
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  8. P Elmer
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  9. P Greenland
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  10. D Jones
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  11. H Kesteloot
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  12. L Kuller
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  13. D Labarthe
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  14. K Liu
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  15. A Moag-Stahlberg
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  16. M Nichaman
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  17. A Okayama
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  18. N Okuda
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  19. C Robertson
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  20. B Rodriguez
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  21. M Stevens
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  22. H Ueshima
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  23. L Van Horn
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  24. B Zhou
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for the INTERMAP Research Group

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Correspondence to J Stamler.

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Stamler, J., Elliott, P., Appel, L. et al. Higher blood pressure in middle-aged American adults with less education—role of multiple dietary factors: The INTERMAP Study. J Hum Hypertens 17, 655–664 (2003). https://doi.org/10.1038/sj.jhh.1001608

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