Blood pressure in black, white and Asian factory workers in Birmingham

Hypertension awareness, treatment and control among ethnic minority populations in Europe: a systematic review and meta-analysis

OBJECTIVE

Ethnic minority populations (EMPs) are disproportionally affected by hypertension-mediated complications compared with European host populations (EHPs), which might be due to disparities in hypertension awareness, treatment and control. We conducted a systematic review and meta-analysis to compare awareness, treatment and control rates among EMPs with EHPs.

METHODS

MEDLINE, EMBASE and Web of Science were searched from inception to 29 January 2020. Critical appraisal was performed according to methods of Hoy et al. Pooled odds ratios with corresponding 95% confidence intervals were calculated for these rates, stratified by ethnic group, using either random or fixed effect meta-analysis based on I2-statistics. Study was registered in PROSPRO (CRD42020107897).

RESULTS

A total of 3532 records were screened of which 16 were included in the analysis with data on 26 800 EMP and 57 000 EHP individuals. Compared with EHPs, African origin populations were more likely to be aware (odds ratio 1.26, 95% confidence interval 1.02-1.56) and treated (1.49, 1.18-1.88) for hypertension, but were less likely to have their blood pressure controlled (0.56, 0.40-0.78), whereas South Asian populations were more likely to be aware (1.15, 1.02-1.30), but had similar treatment and control rates. In Moroccan populations, hypertension awareness (0.79, 0.62-1.00) and treatment levels (0.77, 0.60-0.97) were lower compared with EHPs, while in Turkish populations awareness was lower (0.81, 0.65-1.00).

CONCLUSION

Levels of hypertension awareness, treatment and control differ between EMPs and EHPs. Effort should be made to improve these suboptimal rates in EMPs, aiming to reduce ethnic inequalities in hypertension-mediated complications.

Heterogeneity in blood pressure in UK Bangladeshi, Indian and Pakistani, compared to White, populations: divergence of adults and children

Blood pressure (BP) and hypertension prevalence differences between UK South Asians (Bangladeshis, Indians and Pakistanis) and White Europeans exist in childhood and adulthood. This meta-analysis sought to quantify these differences. We searched MEDLINE (1946-2017), EMBASE (1974-2017) and GLOBAL HEALTH (1973-2017) for comparative studies and pooled the data with Revman (Cochrane Collaboration). Twenty-two studies were included-fourteen on adults and eight on children. South Asian adults had lower systolic and slightly lower diastolic BP. However, stark heterogeneity existed between South Asian subgroups: Bangladeshis had markedly lower systolic BP (mean difference: -11.7 mmHg in men and women), Indians slightly lower (-2.0 mmHg in men and -4.5 mmHg in women) and Pakistanis intermediately lower (-7.9 mmHg in men and -8.6 mmHg in women), compared to White Europeans. However, South Asian children did not have lower systolic or diastolic BP compared to White children, and their BP was often higher. This intergenerational change in BP difference mirrored the change in body mass index difference, particularly in Bangladeshis. We conclude that ethnicity-related BP differences are heterogeneous and dependent on age, sex and South Asian subgroup. South Asian children do not have lower BP than White Europeans in contrast to their adult counterparts. There is concern that this pattern may continue into adulthood, worsening the already high cardiovascular disease burden in South Asians in future years. Further research is needed to ascertain the causes of this evolving issue.

Beliefs about hypertension among Nigerian immigrants to the United Kingdom: A qualitative study

Objective

The aim of the study was to elicit beliefs about hypertension among Nigerian immigrants in the United Kingdom.

Background

The distributions of cardiovascular risk factors and diseases are not shared equally across ethnic and economic groups in the United Kingdom. Its burden is more clustered among minority ethnic populations and migrant groups including black African Nigerian migrants. Similar patterns have been reported across Europe, Australia, Canada, Nordic countries and the United States of America. There are about 300 distinct ethnic groups in Nigeria and reliable information about their beliefs about hypertension is not available. Given that the United Kingdom has a large community of Nigerian immigrants from these different ethno-cultural backgrounds, understanding their unique beliefs about hypertension may help promote appropriate care for this population in the United Kingdom and Nigeria.

Setting

A single Pentecostal church community in West London

Participants

Twenty-seven Nigerian migrant members of the church entered and completed the study

Methods and outcome measure

A qualitative interview study was conducted. The interviews were analysed using thematic framework analysis. The outcome measures were emerging themes from the thematic framework analysis.

Results

Participants expressed beliefs in four major areas related to hypertension: (1) The Meaning of the term hypertension, (2) Perceptions of causation, (3) Effects of hypertension, and (4) Perceptions of treatment. The study revealed a diversity of beliefs about hypertension which incorporated both orthodox and culturally framed ideas.

Conclusions

This study identified important beliefs among Nigerian migrants about hypertension that can contribute to our understanding of the management of hypertension in this group and suggests the need for further research to determine whether these beliefs may be representative of this group.

Ethnic differences in blood pressure monitoring and control in south east London

BACKGROUND

High blood pressure is the single most important risk factor worldwide for the development of cardiovascular disease, and has been shown to affect some ethnic minority groups disproportionately.

AIM

To explore ethnic inequalities in blood pressure monitoring and control.

METHOD

Data from Lambeth DataNet was used, based on case records from GP practices in one inner-city London borough. Blood pressure monitoring and control was compared using Quality and Outcomes Framework (QOF) targets for patients with: diabetes, coronary heart disease, stroke, hypertension, and chronic kidney disease. The study controlled for age, sex, social deprivation, and clustering within GP practices.

RESULTS

A total of 16 613 patients met the study criteria, with 5962 categorised as black/black British. Blood pressure monitoring was similar across ethnic groups and as good, if not better, for black patients compared to white. However, marked ethnic inequalities in blood pressure control were found, with black patients significantly less likely to achieve QOF targets than their white counterparts (odds ratio [OR] 0.73; 95% confidence interval [CI] = 0.64 to 0.82). Further inequalities were revealed in blood pressure control within disease groups and ethnic subgroups. In particular, blood pressure control was poor in African patients with diabetes (OR 0.63; 95% CI = 0.50 to 0.79) and Caribbean patients with coronary heart disease (OR 0.53; 95% CI = 0.37 to 0.77) when compared with white patients.

DISCUSSION

While black patients with chronic conditions are equally likely to have their blood pressure monitored, their blood pressure control is consistently poorer than that of their white counterparts. This may have important implications for cardiovascular risk management in black patients.

Type 2 diabetes and cardiovascular risk in the UK south Asian community

A popular hypothesis for the greater prevalence of type 2 diabetes and cardiovascular disease in UK south Asians is that they have an increased susceptibility of developing insulin resistance in response to certain environmental factors, including obesity and adoption of a sedentary lifestyle. Insulin resistance is postulated as a central feature of the metabolic syndrome, culminating in type 2 diabetes, atherosclerotic vascular disease and CHD; a pathway potentially accelerated by migration/urbanisation. We describe and compare the prevalence of type 2 diabetes, cardiovascular disease and their associated risk factors in UK south Asian and white Caucasian populations to determine possible reasons for the increased preponderance of these diseases in south Asians, and highlight key evidence for optimal risk factor management. Finally, we describe a UK community-based programme that attempts to reduce the morbidity and mortality from type 2 diabetes and cardiovascular disease in south Asians through a new approach to management.

An international comparative study of blood pressure in populations of European vs. African descent

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.

Is the blood pressure of people from African origin adults in the UK higher or lower than that in European origin white people? A review of cross-sectional data

The aim of the study was to review published evidence on whether blood pressure (BP) levels and the prevalence of hypertension are higher in adult populations of African descent living in the UK as compared to the white population. A systematic literature review was carried out using MEDLINE 1966-2002 and EMBASE 1980-2002 and citations from references. In all, 14 studies were identified. Nearly all studies were carried out in the London area. The data showed important differences between studies in terms of age and sex of samples, definition of African/black and methods of evaluating BP. A total of 10 studies reported higher mean systolic BPs, while 11 studies reported higher mean diastolic BPs in men from African descent compared to white men. In women, 10 of 12 studies reported higher systolic, and 10 of 12 studies reported higher diastolic BPs. For prevalence of hypertension, eight of 10 studies reported higher rates in men from African descent; eight of nine studies showed higher rates of hypertension in women from African descent. Overall, the most representative sample and up-to-date data came from the Health Survey for England '99. Ethnic group differences in BP were not present in the younger age groups. Women of African descent had higher BP and higher body mass index (BMI). In men of African descent high BP did not coincide with higher BMI. In conclusion, the reported higher rates of hypertension in people from African descent in the UK are confirmatory of the USA African-American and white comparisons. Variations in study methods, size and body composition, and in the mix of Afro-Caribbean and West African groups explain much of the inconsistent results in the UK studies.

Is the blood pressure of South Asian adults in the UK higher or lower than that in European white adults? A review of cross-sectional data

The objective of the study was to review published evidence on whether blood pressure levels and the prevalence of hypertension are higher or lower in South Asian adults living in the UK as compared to white populations. A systematic literature review was carried out using MEDLINE 1966-2001, EMBASE 1980-2001, and citations from references. A total of 12 studies were identified. The data showed important differences between studies in terms of age and sex of samples, definition of South Asians (Indian, Pakistani and Bangladeshi) and methods of evaluating blood pressure. Seven studies reported lower mean systolic blood pressures, while seven studies showed higher diastolic pressures in South Asian men compared to white men. In women, six of nine studies showed lower systolic blood pressures, while five reported higher diastolic pressures. For prevalence of hypertension, five of 10 studies reported higher rates in South Asian men than in white men. Two of six studies showed higher prevalence rates in South Asian women. Overall, the most representative sample and up-to-date data came from the Health Survey of England 1999. Both blood pressure and the prevalence data show important differences between South Asian subgroups, yet most studies combined them. The data also showed a geographical variation between London (comparatively high blood pressure in South Asians) and the rest of the UK (comparatively low or similar blood pressure). Bangladeshis had low blood pressure and body mass index (BMI). In other South Asian subgroups, low blood pressure and the low BMI did not always coincide. To conclude, the common perception that blood pressure in South Asians is comparatively high is unreliable-the picture is complex. Overall, blood pressures are similar but there is stark heterogeneity in the South Asian groups, with slightly higher blood pressure in Indians, slightly lower blood pressure in Pakistanis, and much lower blood pressure in Bangladeshis. Variations in study methods, body shape, size and fat, and in the mix of South Asian groups probably explain much of the inconsistency in the results.

Ethnic differences in mortality from ischaemic heart disease and cerebrovascular disease in England and Wales

OBJECTIVE

To examine mortality from ischaemic heart disease and cerebrovascular disease in England and Wales by country of birth of the deceased.

DESIGN

Standardised mortality ratios were computed by country of birth groups for ischaemic heart disease and cerebrovascular disease for 1979-83 and 1970-2 by using the five year age-sex specific rates for England and Wales for 1979-83 as standard.

SETTING

England and Wales 1970-2 and 1979-83.

RESULTS

In 1979-83 mortality from ischaemic heart disease was highest in men and women born in the Indian subcontinent (standardised mortality ratio 136 and 146 respectively). Young Indian men suffered the greatest excess (313 at ages 20-29). Other groups with raised mortality included Irish, Scottish, and Polish born immigrants. Those born in the Caribbean, the old Commonwealth, west Europe, and the United States had low death rates. In England and Wales mortality from ischaemic heart disease declined by 5% in men and 1% in women between 1970-2 and 1979-83, with greatest percentage declines in immigrants born in the United States, South Africa, the old Commonwealth, the Caribbean, and France. immigrant groups with raised mortality in the earlier period showed little improvement, and mortality from ischaemic heart disease increased among Indians (6% in men and 13% in women). In 1979-83 mortality from cerebrovascular disease was highest in Caribbeans (standardised mortality ratios 176 in men and 210 in women), followed by Africans, Indians, and Irish. Rates were low in west Europeans. Mortality from stroke declined by 28% overall in this period, a rate of decline shared by most groups. Men from the Indian subcontinent showed a decline of only 3%.

CONCLUSION

In the 1980s mortality from ischaemic heart disease and cerebrovascular disease differed significantly between ethnic groups in England and Wales. In general, ethnic groups that experienced lower mortality from ischaemic heart disease in the 1970s showed the greatest improvement over the following decade.

Blood pressure and migration: a study of Bengali immigrants in East London

The role of blood pressure in explaining the increased risk of ischaemic heart disease (IHD) in Bengali immigrants living in the East End of London was studied in a comparative population study. In addition the effect on blood pressure of age, body mass, and duration of stay in the UK was evaluated. The Bengalis had significantly lower mean systolic and diastolic blood pressures though these differences disappeared after adjustment for age and body mass. Both groups, however, showed similar rises of blood pressure with increasing age and body mass. The effect on blood pressure of duration of time spent in the UK by the Bengalis could not be separated from that due to age, given the association between them. It seems unlikely that increasing duration of stay in inner London per se has a hypertensive effect on Bengali immigrants coming from a rural community. Further, the increased IHD risk in this group is not explained, even in part, by an increase in blood pressure.

United Kingdom Prospective Diabetes Study. III. Prevalence of hypertension and hypotensive therapy in patients with newly diagnosed diabetes. A multicenter study

We measured the blood pressure of 1226 patients with newly diagnosed maturity-onset diabetes, age 25 to 65 years (mean 52 years), mean fasting plasma glucose 11.4 mmol/L. Forty percent of males and 53% of females had hypertension by the World Health Organization criteria of either having blood pressure more than 160/95 mm Hg or receiving hypotensive therapy. Male patients were less obese than female patients (21% and 40% over ideal weight respectively) and a mean 1.3 years younger. Blood pressure was higher in women than men, but it was not significantly greater if age and obesity were taken into account. Twenty-three percent of men and 42% of women had already been informed they were hypertensive, and 12% of men and 26% of women were already receiving hypotensive therapy. The prevalence of hypertension in diabetic white patients was greater than that reported in a sex- and age-matched healthy population. The blood pressure of those taking diuretics was not significantly greater than that of untreated patients, but the 8% of men and 13% of women receiving other hypotensive drugs still had significantly higher blood pressure than the untreated patients. Both patients treated by diuretics and those treated by other hypotensive agents had significantly higher mean plasma urea and creatinine concentrations than untreated patients. This may have been induced by therapy, but one cannot exclude the possibility that treated patients already had renal impairment from diabetic, hypertensive, or other pathology.

Pressor effect of alcohol in hypertension

The effect of alcohol on blood-pressure was studied in 16 men with hypertension who regularly drank up to 80 g of alcohol daily. Antihypertensive treatment was stopped 2 weeks before the men were admitted to hospital for a 7-day study. Blood pressure remained high in 8 patients who continued their regular alcohol consumption up to the fourth day after admission. In the next 4 days no alcohol was taken and diastolic and systolic blood pressures fell significantly. 8 other patients had no alcohol for the first 3 days after admission, but they resumed alcohol consumption from day 4 to 7. In these patients, blood pressure fell slightly after admission. Reintroduction of alcohol produced statistically significant increases in both systolic and diastolic pressures. This study demonstrated a pressor effect of alcohol in patients with hypertension and confirms the link between alcohol and blood-pressure reported in population studies. The mechanism of alcohol-induced hypertension is uncertain and is more likely to be due to an effect of alcohol rather than to the pressor response produced by alcohol withdrawal.