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

J. Stamler*, P. Elliott, L. Appel, Q. Chan, M. Buzzard, B. Dennis, A. R. Dyer, P. Elmer, P. Greenland, D. Jones, H. Kesteloot, L. Kuller, D. Labarthe, K. Liu, A. Moag-Stahlberg, M. Nichaman, A. Okayama, N. Okuda, C. Robertson, B. RodriguezM. Stevens, H. Ueshima, L. Van Horn, B. Zhou

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

86 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)655-775
Number of pages121
JournalJournal of human hypertension
Issue number9
StatePublished - Sep 1 2003


  • Blood pressure
  • Dietary factors
  • Education
  • Nutrition
  • Population study

ASJC Scopus subject areas

  • Internal Medicine


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