BMC Medicine BioMed Central

Research article Open Access

An international comparative study of blood pressure in
populations of European vs. African descent
Richard S Cooper*1, Katharina Wolf-Maier1, Amy Luke1,
Adebowale Adeyemo2, José R Banegas3, Terrence Forrester4,
Simona Giampaoli5, Michel Joffres6, Mika Kastarinen7, Paola Primatesta8,
Birgitta Stegmayr9 and Michael Thamm10

Address: 1Department of Preventive Medicine and Epidemiology, Loyola University Stritch School of Medicine, Maywood, IL, USA, 2Department
of Pediatrics, University College Hospital, Ibadan, Nigeria, 3Departamento de Medicina Preventiva y Salud Pública, Facultad de Medicina.
Universidad Autónoma de Madrid, Spain, 4Tropical Medicine Research Institute, University of the West Indies, Kingston, Jamaica, 5Istituto
Superiore di Sanità, Laboratorio di Epidemiologia e Biostatistica, Rome, Italy, 6Department of Community Health and Epidemiology, Faculty of
Medicine, Dalhousie University, Halifax, Nova Scotia, Canada, 7Department of Public Health and General Practice, University of Kuopio, Finland,
8Department of Epidemiology and Public Health, University College London Medical School, London, UK, 9Department of Medicine, University

Hospital, Umeå, Sweden and 10Robert-Koch Institut, Berlin, Germany

Email: Richard S Cooper* - rcooper@[Link]; Katharina Wolf-Maier - kwolf3@[Link]; Amy Luke - aluke@[Link];
Adebowale Adeyemo - aadeyemo@[Link]; José R Banegas - [Link]@[Link];
Terrence Forrester - [Link]@[Link]; Simona Giampaoli - [Link]@[Link]; Michel Joffres - [Link]@[Link];
Mika Kastarinen - [Link]@[Link]; Paola Primatesta - [Link]@[Link];
Birgitta Stegmayr - [Link]@[Link]; Michael Thamm - thammm@[Link]
* Corresponding author

Published: 05 January 2005 Received: 09 August 2004

Accepted: 05 January 2005
BMC Medicine 2005, 3:2 doi:10.1186/1741-7015-3-2
This article is available from: [Link]
© 2005 Cooper et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ([Link]
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: The consistent finding of higher prevalence of hypertension in US blacks compared
to whites has led to speculation that African-origin populations are particularly susceptible to this
condition. Large surveys now provide new information on this issue.
Methods: Using a standardized analysis strategy we examined prevalence estimates for 8 white
and 3 black populations (N = 85,000 participants).
Results: The range in hypertension prevalence was from 27 to 55% for whites and 14 to 44% for
blacks.
Conclusions: These data demonstrate that not only is there a wide variation in hypertension
prevalence among both racial groups, the rates among blacks are not unusually high when viewed
internationally. These data suggest that the impact of environmental factors among both
populations may have been under-appreciated.

Background related cardiovascular sequelae in blacks compared to

Population surveys in the US from early in the last century whites [1,2]. The enormous attention focused on this
have consistently documented higher blood pressures and observation has resulted in a dichotomous view of

Page 1 of 8
(page number not for citation purposes)
BMC Medicine 2005, 3:2 [Link]

hypertension risk: whereby populations of African origin ing [6,7]. In summary, individual communities were
are considered more susceptible than all other continental chosen on the basis of apparent representativeness and
groupings and a strong genetic hypothesis of inherent pre- census data were obtained. Sampling was based on prob-
disposition to hypertension among blacks has become the ability proportional to size and was structured to lead to a
conventional wisdom [3-5]. Since this research has been sample equally balanced by gender and age group across
limited primarily to the US, the generalizability of these the 10-year age. The studies of the European-origin popu-
conclusions is open to question. Data on the prevalence lations and African Americans were larger in scope [16].
of hypertension in other genetically-related populations Some were based on a random probability sample of the
of African and European descent constitute important evi- entire nation, while others were a series of regional sam-
dence but have so far not been considered in the debate. ples; none were restricted mainly to a single province or
sub-region within the country (Table 3). Collectively the
International comparative studies on hypertension have studies enrolled 85,000 participants and the number of
been seriously limited by the absence of a valid method of subjects in individual studies ranged from 1,800 to
standardization. In the last decade, however, high quality 23,000. Participation rates varied from 61% to 88%. Sam-
population surveys have been conducted in a wide range pling was conducted mainly on population registries.
of populations that used either careful internal standardi-
zation or sufficiently comparable methods [6-15]. We Data collection methods
report here on the patterns of hypertension prevalence in The examination methods have been reported in detail
a sample of 3 such surveys among blacks from Africa, the previously [6,7,16]. In brief, the mercury sphygmoma-
Caribbean and the US and 8 surveys among whites from nometer was used for BP measurements in every country
the US, Canada and Europe. except England, where the Dinamap 8100 oscillometric
device was used. All studies had at least 2 measurements
Methods and the 2nd BP from the clinic visit was used to create the
Study design mean for the age-gender groups, except for England where
Black populations were drawn from the International Col- the 2nd home BP was used. Hypertension was defined as
laborative Study on Hypertension (ICSHIB) and the BP ≥ 140/90 mmHg or current use of antihypertensive
National Health and Nutrition Survey III [6,16]. A pri- medication.
mary report of ICSHIB demonstrated a gradient in hyper-
tension risk from east to west, parallel to the gradient in Data analysis
socioeconomic development and associated lifestyle [6]. BP, body mass index (BMI), and hypertension prevalence
An extensive process of cross-standardization was incor- were calculated for 5-year age-gender groups and aggre-
porated into ICSHIB to ensure that measurement tech- gated as the primary data file. To achieve maximum over-
nique did not bias the survey results [7]. We subsequently lap we restricted the analysis to 35–74 years for age-
identified surveys on hypertension conducted since 1986 specific estimates of BP and hypertension prevalence, and
that were national in scope in North America and Europe. 35–64 years for age-adjusted results. In the US NHANES
Two North American and six European surveys were whites and blacks were analyzed separately with the
included, viz: US [8] and Canada, [9], England [10], Fin- appropriate weighting for population size. As previously
land [11], Germany [12], Italy [13], Spain [14] and Swe- reported, the prevalence estimates obtained for US blacks
den [15]. The US data from NHANES-III are available for from ICSHIB were virtually identical to those from
public use through the National Center for Health Statis- NHANES [6]; to enhance generalizability, however, we
tics [8]. Investigators in Canada and Europe were con- used the NHANES data to represent the US black popula-
tacted and invited to join this project. More detailed tion. Hypertension prevalence and control was age-
methods for this component of the study were reported adjusted by age-averaging the 5-year age groups combin-
earlier [16]. In brief, after achieving consensus on the ing the data for men and women. For comparison of all
main goals and resolving the methodological issues, data white vs. all black populations the mean BP's and preva-
collection forms were distributed. Each collaborator pro- lences were averaged, considering each country as a single
vided average gender- and age-specific data by 5-year age unit (i.e., without weighting by population size).
groups for BPs, body mass index (BMI), and counts of
hypertensives by treatment and control status. A descrip- Results
tion of the key aspects of each survey, including the BP Patterns of blood pressure
measurement procedure, was collected in a standardized The age-averaged BPs and BMIs are presented for each sur-
format. vey, by gender, in Table 2. It must be recognized that
where treatment is common these data may understate
The surveys that formed the basis of ICSHIB were con- the true values, although this effect is likely to be small
ducted in localized communities by door-to-door screen- when the population is considered as a whole. Trends in

Page 2 of 8
(page number not for citation purposes)
BMC Medicine 2005, 3:2 [Link]

Table 2: Mean Systolic and Diastolic Blood Pressure and Body Mass Index among Persons 35–74 Years, in African- and European-
Origin Populations*

Total Sys / Dias Men Sys / Dias Women Sys / Dias BMI, All

(mmHg) (mmHg) (mmHg) (kg/m2)

African-Origin Populations
Nigeria 121.5/72.4 122.2/73.0 121.0/71.9 22.9
Jamaica 122.9/71.7 122.5/72.0 123.2/71.5 27.0
US – Black 129.7/78.5 130.3/80.8 129.1/76.3 28.5
European-Origin Populations
US – White 120.9/75.2 123.4/78.2 118.3/72.2 27.3
Canada 128.2/80.8 131.2/83.2 125.1/78.5 26.8
Italy 129.8/83.1 132.4/85.4 127.2/80.7 26.4
Sweden 130.6/80.9 133.0/83.4 128.3/78.4 26.5
England 135.0/77.2 137.3/80.3 132.7/74.2 27.1
Spain 131.4/83.2 132.3/83.9 130.5/82.5 27.4
Finland 134.3/83.8 136.9/86.0 131.6/81.5 27.1
Germany 138.0/86.4 139.5/88.5 137.3/84.3 27.3

* Age-adjusted

Table 3: Hypertension Prevalence (%) among Persons 35–64 Years, in African- and European-Origin Populations *

Total (%) Men (%) Women (%)

African-Origin Populations
Nigeria 13.5 13.9 13.1
Jamaica 28.6 23.4 31.8
US – Black 44.0 43.1 44.8
European-Origin Populations
US – White 26.8 29.7 23.9
Canada 27.4 31.0 23.8
Italy 41.5 48.0 35.1
Sweden 38.4 44.8 32.0
England 41.7 46.9 36.5
Spain 46.8 49.0 44.6
Finland 48.6 55.7 41.6
Germany 55.3 60.2 50.4

* Age-adjusted

BP with age showed considerable heterogeneity within ent (Table 3, Figure 4). Among the 14 populations, US
population groups of both continental ancestry (i.e. Afri- blacks fall near the middle in terms of prevalence (mean
can and European) (Figures 1, 2). In rural Nigeria, mean prevalence = 37%, U.S. blacks = 44%). Among those
BPs were low and rose only modestly with age (Figure 1). above the mean, all but one is of European origin. Impor-
Intermediate levels of BP were observed in Jamaica, while tant differences are apparent in the gender-specific preva-
the US blacks had higher BPs at all ages. As previously lence hypertension in these groups. Among Jamaican
reported, whites in the US and Canada had substantially women hypertension was substantially more common
lower BPs over the entire life span than did the Europeans than among Jamaican men (32% vs. 23%), and relative
(Figure 2). For greater clarity, the age-specific patterns are gender equality existed for US blacks. In Europe, however,
presented for all black and all white groups combined the prevalence of hypertension was higher among men in
(Figure 3). every country (range 5–10%).

Hypertension prevalence Hypertension prevalence and obesity

Hypertension prevalence, which accounts for the effect of The only etiological factor on which standardized infor-
treatment, follows a similar pattern although the east-west mation was available was obesity, measured by its proxy
gradient among the African-origin groups is more consist- BMI. The correlation between average BMI and hyperten-

Page 3 of 8
(page number not for citation purposes)
BMC Medicine 2005, 3:2 [Link]

150

140
160
SBP (mmHg)

130 Nigeria 150

SBP (mmHg)
Jamaica 140 Mean BP, African
120 US Blacks Descent
130
Mean BP,
120 European Descent
110
110
100 100
35-44 45-54 55-64 65-74 35-44 45-54 55-64 65+
Age (years) Age (years)

Mean
By AgeSystolic
Figure Group
1 Blood Pressure, African Descent Populations; Figure
Mean
Populations;
Systolic
3 By Blood
Age Pressure,
Group African and European Descent
Mean Systolic Blood Pressure, African Descent Populations; Mean Systolic Blood Pressure, African and European Descent
By Age Group Populations; By Age Group

Discussion
Comparisons of BP distributions across populations are
made difficult by the requirement of comparability of the
160
Canada survey methods. In the last two decades, however, adop-
150 England tion of standardized protocols along with rigorous train-
SBP (mmHg)

Finland
ing have greatly improved the quality of epidemiological
140
Germany
studies of hypertension [6,17-19]. A number of countries
130 now conduct recurring national surveys that monitor both
Italy
secular trends and regional variation within the country
120 Spain
[10-12,19,20]. While independent surveys from the same
Sweden
110 base population had given divergent results in the past, at
35-44 45-54 55-64 65-74
USA Whites least two recent single-community studies conducted in
Age (years) the US provided estimates virtually identical to NHANES
[21,22]. Although this evidence does not diminish the
requirement of careful assessment of survey methodology
Figure
Mean
tions; Systolic
By2Age Group
Blood Pressure, European Descent Popula-
Mean Systolic Blood Pressure, European Descent Popula- before making comparisons, it does demonstrate that reli-
tions; By Age Group able information can be obtained from independent
studies.

The data presented here demonstrate a two-fold variation

in prevalence of hypertension in both European- and Afri-
sion prevalence was 0.6 (p < 0.01), all populations com- can-origin populations. The prevalences are similar in
bined. Within the black populations the same correlation blacks in the US and whites in Europe, although impor-
was observed between mean BMIs and hypertension prev- tant gender differences are apparent. Although not a sys-
alence (r = 0.6). Among whites, however, the relationship tematic sample, the populations that are included
was weaker (r = 0.3). Of course, since obesity will be cor- generally reflect the characteristic social setting in which
related with many other aspects of lifestyle, it is difficult to these groups are found around the world. Summed across
infer whether weight gain itself is playing a less important all groups, the white populations on average have a sub-
role in determining the variation among white popula- stantially higher burden of hypertension. This result can
tions. The contrasts noted above in hypertension preva- be attributed in large part to the inclusion of several black
lence by gender are consistent with the relative excess of samples from developing countries where risk factors for
obesity in women compared to men among Jamaicans hypertension are presently at a lower level. In the only
and US blacks [2,6]. head-to-head comparison within the same survey, US
blacks have a prevalence that is 50% higher than among

Page 4 of 8
(page number not for citation purposes)
BMC Medicine 2005, 3:2 [Link]

60
50
Hypertension
Prevalence of

40
30
20
10
0
a

y
En y

d
en

Fi n
s

ks
ca

d
ia

ad
te

an
al

an

ai

an
er

ai

ac
ed
hi

It

Sp
an

m
gl

nl
m
ig

Bl
W

Sw

er
C

Ja
N

G
S

U
U

Adjusted4
Hypertension
Figure Prevalence (140/90 mmHg or Treatment), African and European Descent Populations; Ages 35–64, Age
Hypertension Prevalence (140/90 mmHg or Treatment), African and European Descent Populations; Ages 35–64, Age
Adjusted

whites. Data from the UK, including the national survey, vital statistics indicator of uncontrolled high BP – are
also demonstrate higher BPs and more hypertension strongly correlated with the prevalence of hypertension
among blacks of Caribbean and African descent [23-27]. among these countries ('r' = 0.8) [16]. Although the data
On the whole, however, the published literature on racial are more limited, hypertension appears to be even more
disparities in hypertension from the UK is less consistent common in Eastern Europe [32-34]. In a comparison of
than in the US, where essentially every study has reported Pol-MONICA with the US-based ARIC study, systolic BPs
higher rates among blacks [28]. Surveys from Cuba, Trini- in Poland were 20 mmHg higher than in the US [3].
dad and Brazil have also shown a smaller black-white gra-
dient in BP than found in North America [29-31]. The primary purpose of this analysis was to provide
descriptive results and very limited information was avail-
Are these findings merely artifactual, reflecting either able on factors that might explain the findings we
methodological error or the sampling process? The most observed. The gradient among the black populations is
unexpected features of the data presented here are the consistent with the transition to an industrialized lifestyle
high rates of hypertension in Europe, when contrasted to and is thereby collinear with most known risk factors [6].
whites in Canada and the US. These results have been BMI is serving as an effective proxy for this relationship,
reported in greater detail in an earlier publication [16]. It although its independent contribution cannot be quanti-
is beyond the usual standard of statistical significance for fied. The explanation of the European-North American
the six European surveys to be higher by chance than both contrasts among the white populations is not as apparent.
of those in North America (p < 0.05). As previously dem- As we have discussed elsewhere, either known risk factors
onstrated, mortality rates for stroke – the most sensitive other than obesity are having a larger impact at the popu-

Page 5 of 8
(page number not for citation purposes)
BMC Medicine 2005, 3:2 [Link]

lation level than usually appreciated, or unknown factors tal influences must be at work that are not apparent on the
are at work [16]. In either case, further examination of this surface. A similar process could be taking place across the
question seems justified. social environments into which persons of African origin
are assorted within societies such as the US and the UK.
Treatment guidelines and practice patterns vary widely The debate over inherent susceptibility cannot be resolved
among these countries [16-19]. Widespread treatment with these data since neither the genetic nor the environ-
could, of course, alter the mean BPs in a population, mental influences can be held constant, allowing a test of
although this effect would be confined to persons over 55 the relative influence of the other factor. In fact, the ques-
where hypertension is common. The US has the highest tion of inherent susceptibility is probably non-testable
rate of treatment, with about 25% of hypertensives con- under any circumstances [35-37]. While the assumption is
trolled, compared to 10% in Europe and less than 1% in often made that contrasting environmental influences
Africa (with hypertension defined as 140/90 mmHg)[16]. between blacks and whites can be adjusted by using proxy
Any biases that would be introduced into the cross- measures such as education, that assumption does not
national comparisons by differential treatment and con- hold up under close examination [38]. Perhaps more to
trol are insufficient to alter the primary conclusions, how- the point, however, these data demonstrate that the con-
ever. The virtual absence of treatment in rural Africa sistent emphasis given to the genetic elements of the racial
would mean that the natural distribution has essentially contrasts may be a distraction from the more relevant
been observed unaltered. The effect of treatment in the US issue of defining and intervening on the preventable
or Canada would not be apparent in younger individuals, causes of hypertension, which are likely to have a similar
where contrasts in BPs with Europe and Africa are equally impact regardless of ethnic and racial background [39].
large. Once the problem of ethnic/racial contrasts is character-
ized more closely as a special instance of environmental
If the North American-European contrasts are occurring in influences at the population level, it could become more
genetically homogeneous populations, large environmen- tractable in both the realms of research and practice.

Table 1: Characteristics of the Surveys

Country Survey Yr(s) Population N Male (%) Participation Age Range Sampling
Rate (%) Method*

Nigeria 1991–93 Local 1931 45 NA 25–74 Multistage,

address
Jamaica 1993–95 Local 2573 41 65 25–74 Multistage,
address
USA, NHANES 1988–94 National 5283 45 82 18–80+ Multistage,
Black population
registry
Canada 1986–92 National 23129 49 77.5 18–74 Multistage,
medical
insurance
registries
England 1998 National 11884 45 87.5 16–80+ Multistage, post
code address
Finland 1997 National 7064 47 72 25–64 Population
registry
Germany 1997–99 National 7047 49 61.4 18–79 Population
registry
Italy 1998 National 8233 50 - 35–74 Multistage,
population
registry
Spain 1990 National 2021 40 73 35–65 Multistage,
national registry
Sweden 1999 Regional 1823 49 72 25–74 Population
registry
USA NHANES 1988–94 National 7252 46 82 18–80+ Multistage,
White population
registry

* All stratified sampling methods

Page 6 of 8
(page number not for citation purposes)
BMC Medicine 2005, 3:2 [Link]

Competing interests experience at the Cardiovascular Epidemiologic

Observatory. Ital Heart J Suppl 2001, 2:294-302.
The author(s) declare that they have no competing 14. Banegas JR, Rodriguez-Artalejo F, de la Cruz Troca JJ, Guallar-Castil-
interests. lon P, del Rey Calero J: Blood pressure in Spain: distribution,
awareness, control, and benefits of a reduction in average
pressure. Hypertension 1998, 32:998-1002.
Authors' contributions 15. Stegmayr B, Harmsen P, Rajakangas AM, Rastenyte D, Sarti C, Thor-
RC, KWM, AL and JB were responsible for study concept, valdsen P, Tuomilehto J: Stroke around the Baltic Sea: Inci-
design and supervision. RC, KWM, JB, SG, MJ, AA, TF MK, dence, case fatality and population risk factors in Denmark,
Finland, Sweden and Lithuania. Cerebrovasc Dis 1996, 6:80-88.
PP, BS and MT were involved in data acquisition. RC, 16. Wolf-Maier K, Cooper RS, Banegas JR, Biampaoli S, Hense H, Joffres
KWM, JB, MJ, PP and AL were responsible for analysis and M, Kastarinen M, Poulter N, Primatesta P, Rodriguez-Artalejo F,
Stegmayr B, Thamm M, Tuomilehto J, Vanuzzo D, Vescio F: Hyper-
interpretation of data. RC and KWM drafted the manu- tension and blood pressure level in six European countries,
script. RC, JB, SG, AL, AA, TF, MJ, MK, PP, BS and MT were Canada and the US. JAMA 2003, 289:2363-2369.
involved in critical revision of the manuscript for 17. The WHO MONICA Project. Geographical variation in the
major risk factors of coronary heart disease in men and
important intellectual content. Statistical expertise was women aged 35–64 years. World Health Stat Q 1988, 41:115-140.
provided by MJ. Administrative, technical and material 18. Wolf HK, Tuomilehto J, Kuulasmaa K, Domarkiene S, Cepaitis Z,
Molarius A, Sans S, Dobson A, Keil U, Rywik S: Blood pressure lev-
support was provided by KWM, MK, and BS. els in the 41 populations of the WHO MONICA Project. J
Hum Hypertens 1997, 11:733-742.
Acknowledgements 19. Burt VL, Cutler JA, Higgins M, Horan MJ, Labarthe D, Whelton P,
Brown C, Roccella EJ: Trends in the prevalence, awareness,
The authors are grateful for the use of the data from the Osservatorio Epi-
treatment, and control of hypertension in the adult US pop-
demiologico Cardiovascolare, Italy. We would like to thank Guichan Cao ulation. Data from the health examination surveys, 1960 to
for assistance in data management and analysis at Loyola University. Funding 1991. Hypertension 1995, 26:60-69.
was provided by the Centers for Disease Control and Prevention, USA. 20. Hajjar I, Kotchen T: Regional variations of blood pressure in the
United States are associated with regional variations in die-
tary intakes: The NHANES-III data. J Nutr 2003, 133:211-214.
This work was supported by a grant from the Cardiovascular Branch of the 21. Freeman V, Rotimi C, Cooper R: Hypertension prevalence,
US Centers for Disease Control and Prevention, Atlanta, GA (Cooperative awareness, treatment, and control among African Ameri-
agreement 0755). cans in the 1990s: Estimates from the Maywood Cardiovas-
cular Survey. Am J Prev Med 1996, 12:177-185.
22. Victor RG, Haley RW, Willett DL, Peshock RM, Vaeth PC, Leonard
References D, Basit M, Cooper RS, Iannacchione VG, Visscher WA, Staab JM,
1. Lackland DT, Keil JE: Epidemiology of hypertension in African Hobbs HH, Dallas Heart Study Investigators: The Dallas Heart
Americans. Semin Nephrol 1996, 16:63-70. Study: a population-based probability sample for the multi-
2. Cooper R, Rotimi C: Hypertension in blacks. Am J Hypertens 1997, disciplinary study of ethnic differences in cardiovascular
10:804-812. health. Am J Cardiol 2004, 93:1473-1480.
3. Cooper RS, Rotimi C: Hypertension in populations of West 23. Primatesta P, Bost L, Poulter NR: Blood pressure levels and
African origin: Is there a genetic predisposition? J Hypertens hypertension status among ethnic groups in England. J Hum
1994, 12:215-227. Hypertens 2000, 14:143-148.
4. Brewster LM, Clark JF, van Montfrans GA: Is greater tissue activ- 24. Cruickshank JK, Jackson SH, Bannan LT, Beevers DG, Beevers M,
ity of creatine kinase the genetic factor increasing hyperten- Osbourne VL: Blood pressure in black, white and Asian factory
sion risk in black people of sub-Saharan African descent? J workers in Birmingham. Postgrad Med J 1983, 59:622-626.
Hypertens 2000, 18:1537-1544. 25. Lane D, Beevers DG, Lip GYH: Ethnic differences in blood pres-
5. Grim CE, Robinson M: Blood pressure variation in blacks: sure and prevalence of hypertension in England. J Hum
genetic factors. Semin Nephrol 1996, 16:83-93. Hypertens 2002, 16:267-273.
6. Cooper R, Rotimi C, Ataman S, McGee D, Osotimehin B, Kadiri S, 26. Cappuccio FP, Cook DG, Atkinson RW, Wicks PD: The Wands-
Muna W, Kingue S, Fraser H, Forrester T, Bennett F, Wilks R: worth Heart and Stroke Study. A population-based survey of
Hypertension prevalence in seven populations of African cardiovascular risk factors in different ethnic groups. Meth-
origin. Am J Public Health 1997, 87:160-168. ods and baseline findings. Nutr Metab Cardiovasc Dis 1998,
7. Ataman SL, Cooper R, Rotimi C, McGee D, Osotimehin B, Kadiri S, 8:371-385.
Kingue S, Muna W, Fraser H, Forrester T, Wilks R: Standardization 27. Chaturvedi N, McKeigue PM, Marmot MG: Resting and ambula-
of blood pressure measurement in an international compar- tory blood pressure differences in Afro-Caribbeans and
ative study. J Clin Epidemiol 1996, 49:869-877. Europeans. Hypertension 1993, 22:90-96.
8. Burt VL, Whelton P, Roccella EL, Brown C, Cutler JA, Higgins M, 28. Agyemang C, Bhopal R: Is the blood pressure of people from
Horan MJ, Labarthe D: Prevalence of hypertension in the US African origin adults in the UK higher or lower than that in
adult population. Results from the Third National Health European origin white people? A review of cross-sectioned
and Nutrition Examination Survey, 1988–1991. Hypertension data. J Human Hypertens 2003, 17:523-534.
1995, 25:305-313. 29. Ordunez-Garcia PO, Espinosa-Brito AD, Cooper RS, Kaufman JS,
9. Joffres MR, Ghadirian P, Fodor JG, Petrasovits A, Chockalingam A, Nieto FJ: Hypertension in Cuba: Evidence of a narrow black-
Hamet P: Awareness, treatment, and control of hypertension white difference. J Human Hypertens 1998, 12:111-116.
in Canada. Am J Hypertens 1997, 10:1097-1102. 30. Miller GJ, Maude GH, Beckles GL: Incidence of hypertension and
10. Primatesta P, Brooks M, Poulter NR: Improved hypertension non-insulin dependent diabetes mellitus and associated risk
management and control: results from the Health Survey factors in a rapidly developing Caribbean community: the St
for England 1998. Hypertension 2001, 38:827-832. James survey, Trinidad. J Epidemiol Community Health 1996,
11. Kastarinen MJ, Salomaa VV, Vartiainen EA, Jousilahti PJ, Tuomilehto 50:497-504.
JO, Puska PM, Nissinen AM: Trends in blood pressure levels and 31. James SA, de Almeida-Filho N, Kaufman JS: Hypertension in Brazil:
control of hypertension in Finland from 1982 to 1997. J a review of the epidemiological evidence. Ethn Dis 1991,
Hypertens 1998, 16:1379-1387. 1:91-98.
12. Thamm M: Blood pressure in Germany – current status and 32. Rywik SL, Davis CE, Pajak A, Broda G, Folsom AR, Kawalec E, Wil-
trends. Gesundheitswesen 1999, 61:S90-S93. liams OD: Poland and U.S. Collaborative Study on Cardiovas-
13. Giampaoli S, Palmieri L, Dima F, Pilotto L, Vescio MF, Vanuzzo D: cular Epidemiology. Hypertension in the community:
Socioeconomic aspects and cardiovascular risk factors: Prevalence, awareness, treatment, and control of hyperten-

Page 7 of 8
(page number not for citation purposes)
BMC Medicine 2005, 3:2 [Link]

sion in the Pol-MONICA Project and the U.S. Atherosclero-

sis Risk in Communities study. Ann Epidemiol 1998, 8:3-13.
33. Strasser T: Hypertension: The East European experience. Am
J Hypertens 1998, 11:756-758.
34. Tyroler HA, Gasunov IS, Deev AD: A comparison of high blood
pressure prevalence and treatment status in selected US
and USSR populations. First Joint US-USSR Symposium on
Hypertension. Bethesda, Md: NIH DHEW publication 79-1272,
Bethesda, MD; 1979.
35. Kaufman J, Cooper RS: Seeking causal explanations in social
epidemiology. Am J Epidemiol 1999, 150:113-120.
36. Cooper RS, Kaufman JS: Race and hypertension: Science or
nescience? Hypertension 1998, 32:813-816.
37. Mountain JL, Risch N: Assessing genetic contributions to phe-
notypic differences among 'racial' and 'ethnic' groups. Nat
Genet 2004, 36(11 Suppl):S48-53.
38. Kaufman JS, Cooper RS, McGee D: Socioeconomic status and
health in blacks and whites: The problem of residual con-
founding and the resiliency of race. Epidemiology 1997,
8:621-628.
39. Cooper RS, Kaufman J, Ward R: Race and genomics. N Engl J Med
2003, 348:1166-1170.

Pre-publication history
The pre-publication history for this paper can be accessed
here:

[Link]

Publish with Bio Med Central and every

scientist can read your work free of charge
"BioMed Central will be the most significant development for
disseminating the results of biomedical researc h in our lifetime."
Sir Paul Nurse, Cancer Research UK

Your research papers will be:

available free of charge to the entire biomedical community
peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central
yours — you keep the copyright

Submit your manuscript here: BioMedcentral

[Link]

Page 8 of 8
(page number not for citation purposes)