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Blood pressure and body size preference in traditional communities of Ilorin metropolis, Nigeria

Okoro, Emmanuel O.a; Etebu, Ebitimitula N.c; Oyejola, Benjamin A.b

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Cardiovascular Endocrinology: June 2015 - Volume 4 - Issue 2 - p 53-59
doi: 10.1097/XCE.0000000000000048
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Weight reduction is a widely adopted intervention for minimizing the risk of developing and controlling hypertension in many jurisdictions including Nigeria 1–3. However, weight loss is not always easy for everyone, with some studies 4–6 indicating that fewer than 20% of individuals attempting to do so actually maintained lost weight over time. Moreover, many individuals with elevated blood pressure (BP) are neither overweight nor obese. In some groups, the dominant body type associated with hypertension is lean 7–9. These observations could raise the intriguing possibility that mechanism(s) beyond excess weight may be more important in driving an increase in BP, at least in some groups.

Furthermore, body size is often tied to the notion of beauty, and body figure preference can vary with community to the extent that what is considered desirable in one group may be viewed differently in another 10–17. Specifically, how individuals perceive their body size in relation to the preferred body figure in their group can affect self-esteem and influence weight-control behaviour 10,14. Not long ago, we observed 18 a preference for larger body figures in a cohort of middle-age/elderly Nigerians with type 2 diabetes. More recent data 19 suggest that this body size preference may be more widespread in the background population than considered previously, particularly in some Yoruba-speaking communities in the wider Ilorin city with a thriving metropolis of over one million individuals.

As these observations could have implications for interventions, aimed at minimizing the risk of hypertension on the basis of weight control, we examined the role of BMI, waist circumference (WC) and body size perception (perceived and desired) in the determination of BP. The study aimed to ascertain, if any, the relationship between indicators of body size and BP and to determine which indicators (if any) can be used to predict BP. In this work, BMI and WC were used as anthropometric measures of actual body size and shape, respectively 19–22. This work, therefore, describes our observations and is presented under the following headings: method (including the participants involved, experimental tools used and procedures adopted for data acquisition), results and comment on the findings.

An oral presentation of part of these data was made to the Nigerian Society of Endocrinology and Metabolism at its 33rd Annual Scientific Meeting in Kaduna, Nigeria, 21–23 September 2011 23, and to the World Health Organization Collaborating Centre for International Drug Monitoring Research Conference entitled ‘RISK: What risk? Whose risk?’ at Uppsala, Sweden, 22–23 May 2014 24.


Study population, ethics and community mobilization

These have been detailed elsewhere 18,19. The study was carried out in the traditional communities of Okelele, Idi-Ape and Pakata communities in Ilorin, a thriving state capital of over one million individuals in Nigeria. Participants were indigenous individuals aged 18 years or older living in their ancestral homes within the greater Ilorin metropolis. Identified community leaders assisted in mobilizing potential participants. Participation was voluntary, and enrollees could exit the study at any stage without the need for explanations. Neither cash nor free medicines were offered as inducement. Data collection was carried out in 2008.

Experimental tools and procedures

All measurements were carried out by trained research assistants in a tent located in a secluded corner within the compound of the community head.

Demographic/anthropometric parameters of interest including age (in years), body weight in kg, height in cm, WC and hip circumference (HPC) in cm were measured, whereas BMI in kg/m2 was calculated for each volunteer as detailed previously 1,2,20.

Body size perception/preference was measured using the Stunkard Body Figure Test as modified for black individuals 12,13,17. Specifically, volunteers indicated which figure (1–9 in increasing size) most represented their current body size (CBS) and the one they would ideally want to be, that is, preferred body size (PBS). In addition, participants were requested to choose a preferred body size for their spouse or the opposite gender (PBSOG). Reports 17,25 had indicated that how one gender views it body size can be influenced by the preference of the other.

BP was measured with a standard Accosson mercury sphygmomanometer [A.C. Cossor & Son (Surgical) Ltd, Harlow, Essex, UK] using an appropriate-sized cuff that covered at least two-thirds of the upper arm. BP was recorded with the participant sitting comfortably on a chair with the arm rested at the heart level on a table. All measurements were obtained after a 3-min rest by the same observers throughout the study. Systolic blood pressure (SBP) was determined by the first appearance of Kortkoff sound (phase 1) and diastolic blood pressure (DBP) was recorded at the point of disappearance (phase 5). BP readings were to the nearest 2 mmHg and recorded thrice for each participant. The average of the last two readings was considered as the BP for each participant. In volunteers with readings of SBP 140 mmHg or more and/or DBP 90 mmHg or more, BP measurement was repeated on two different dates within 1 week of the first. The average of the three values was used to classify the final BP status of the individual. Participants with persistent values of 140/90 mmHg or above were followed up in the Medical Outpatient Clinics of our hospital. For the purpose of this study, elevated BP was defined as SBP 140 mmHg or more and/or DBP 90 mmHg or more or both.

Statistical analyses

Statistical analyses were carried out using the SPSS 15.0 and S-plus 2000 computer packages (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics were calculated to characterize the sample. In addition, the t-test was used to determine differences in means, whereas the χ2-test was used to compare frequencies. The Pearson correlation coefficient was used to test for a linear relationship between two quantitative variables. In addition, linear regression was used to determine the functional relationship between BP and measures of body size and perception. Stepwise regression analysis was used to select those variables of body size and perception that best relate to BP values. Logistic regression was used to assess the odd ratios of being hypertensive (SBP≥140/90 mmHg and/or DBP≥90 mmHg). A P value of less than 0.05 was considered significant, except when otherwise stated. Cohen’s d, which is an effect size used to indicate the standardized difference between two means, was also calculated. The d values were interpreted as follows: d∼0 implies no or a near-zero effect, d less than 0.2 implies small-size effects, d=0.2–0.5 implies moderate-size effects and d more than 0.5 indicates a large effect.


The study sample included 523 participants, divided into those with elevated BP and a group with normal BP (Table 1). Those with elevated BP tended to have larger body dimensions. The differences in the means of the two groups in all variables were moderately large, except for WC/HPC, for which the means were similar (see P and d values in Table 1). However, the mean BMI values of both groups were lower than 25 kg/m2. A significantly higher proportion (38.1%; i.e. 64 out of 168) of participants with elevated BP had high BMI (≥25 kg/m2) against 26.4% (92 out of 348) of participants with normal BP (χ2=7.30, d.f.=1, P=0.007). The CBS, PBS and PBSOG scores were higher in participants with elevated BP compared with those with normal BP, but the general direction of preferred body figure relative to CBS was upward in both groups (Table 1). In addition, 66.5 and 51.9% of the participants with elevated BP and those with normal BP, respectively, chose a larger body figure of 5 and above (i.e. those with visible fat) as desirable.

Table 1
Table 1:
Comparison of the mean values by blood pressure classification

SBP increased with age, but less so with indicators of body size (Table 2). A similar trend was evident with respect to DBP, but with lower correlations (data not shown for clarity).

Table 2
Table 2:
Pearson’s correlation coefficients (r) between blood pressure (systolic blood pressure) and indicators of body size and age

Relationship between blood pressure and variables of interest

The results of the stepwise linear regression analysis that was used to select indicators of body size that best relate to BP and the functional relationships are as follows:

For the entire group:

Standard errors are in brackets below the coefficients in the equations.

This preliminary analysis did not show any major role for actual body size (BMI) in the relationship with BP. The data were then divided by age into those younger than 50 years of age and those older than 50 years of age in accordance with a previous publication and also because hypertension in Nigerians usually manifests before this age 26–28. The relationship was then examined for each group and yielded the following results:

Those younger than 50 years:

For older participants:

None of the variables showed any significant relationship with DBP.

Similarly, the data were divided by BP into those with elevated BP and those with normal BP, and re-run. This yielded the following equations:

Those with normal BP:

Those with elevated BP:

No systematic relationship was observed between DBP and indicators of body size. Figure 1 summarizes the contribution of body dimensions towards variations in BP on the basis of the R2 value, failing to reach statistical significance (P=0.101) in the group with elevated BP. The results of stepwise logistic regression analyses are summarized in Table 3. CBS emerged as the best indicator of body size to determine whether a participant is likely to have elevated BP or not with a correct classification of BP status of 68.8% (Table 3). The contribution of CBI and any of the other body size indicators yielded a lower per cent of the correct classification. When the combination of age and CBI was used, the correct classification of BP increased marginally to 71%.

Fig. 1
Fig. 1:
Relative contribution of body dimensions (BMI/waist circumference/height) to variations in systolic blood pressure.
Table 3
Table 3:
Stepwise multiple logistic regression analyses of the relationship between blood pressure and indicators of body size and age


The results show that participants with larger body dimensions also had higher BP as indicated by the correlation values. In particular, as WC increased, so did BP (see r values in Table 2). Also, the differences in measurements of body size between the group with elevated BP and those with normal BP were moderately large, except for WC/HPC (Table 1). This is consistent with many previous reports 29–31. However, compared with findings 21,22,32–35 in non-Nigerian groups, particularly African–Americans and whites, the present association between BP and body size indicators appears weak. Even so, the present correlation values were higher than those for age (0.05), BMI (0.088) and WC (0.061) reported by Onwubere et al. 31 in another Nigerian traditional community of a different ethnicity with a prevalence of hypertension of 46.4% compared with 33.1% found in this study. This weak or lack of a relationship between body dimensions and BP has also been observed in other groups particularly within Africa 7,9,29–31,36–38. It should be noted that nearly two-thirds of individuals with elevated BP had a BMI of less than 25 kg/m2, thereby indicating that the dominant body type associated with hypertension in this group was lean. This is consistent with the findings of independent investigators 7,9,36–38. The corollary to this is that about a quarter (26.1%) of those with normal BP were overweight, thus showing that larger body sizes were not always associated with elevated BP in every group 36,39–41.

Importantly, the regression analyses showed that BMI or WC did not have the same effects on BP in all participants. In particular, the functional relationship between SBP and BMI, with a constant of 1.103 and an R2 value of 0.046 in older participants (≥50 years), was comparable with 1.17 and R2 of 0.050 reported by Cappuccio et al.30 from the same ethnic group and region, albeit in men. Interestingly, these quantitative effects of BMI and WC on SBP disappeared once BP was elevated as indicated by a P value of 0.101 of the functional relationship between BP and indicators of body dimensions in the group with elevated BP (see the Results section and Fig. 1). This could mean that the effects of body size on BP may depend on age and whether or not hypertension was present.

Furthermore, the results from the different methods used in the analysis of the present data consistently showed that BMI and WC were rather poor predictors of BP. This consistency reinforces our interpretation that body size was unlikely to be a major determinant of BP in this group, suggesting that differences in body dimensions may not be of major relevance in the determination of BP level in everyperson or group, especially when hypertension is present as others have also argued 7,9,39–43.

This work therefore extends our recent observations 19, whereby BMI and WC accounted for only about 1% of the interindividual differences in blood glucose in this same group that also showed a rather low prevalence of abnormal glucose metabolism, including overt type 2 diabetes, of 0.3% compared with 2.3% and above in other Nigerian cities at the time 44,45. It should be noted that compelling evidence 46–48 has emerged that suggests that hypertension and type 2 diabetes are linked and may share a common disease mechanism. To this extent, our data add to the growing body of evidence 6–8,28,30,32–41,43,44,49–53 showing that body size and/or changing body dimensions may not always affect BP and glucose metabolism in the same way in every individual/group, consistent with the possibility of heterogeneity in the interaction of body size and BP.

Surprisingly, the present results (Table 3) also suggest that how individuals perceive (particularly CBS) their actual body size could in some ways be related to BP (see also regression equations, Tables 2 and 3). This finding could be of concern, given that the majority of respondents (66.5 and 51.9% of the participants with elevated BP and normal BP, respectively), although predominantly of normal size, still desired a larger body figure. The level of correct classification of BP (Table 3) on the basis of CBS as an independent variable was, however, rather low at 68.8% and marginally increased to 71% when combined with age, which is the variable most associated with increasing BP (see the r values in Table 2).

More importantly, the results repeatedly failed to show that differences in body size (BMI), shape (WC) or and whether or not a different body type is desired contributed in any meaningful way towards interindividual differences in BP. This conclusion is reinforced by the R2 values of the various equations defining the functional relationship between BP and the various measures of body size that tend to suggest that over 91% of the participant-to-participant differences in BP are related more to differences other than those because of BMI, WC or body size perception.

Nevertheless, the data also show that large body sizes may be a valuable social asset in these communities as reported widely 10–16 in many black groups of diverse geographic locations and ethnicity. More recent studies 25,54 overseas, however, suggest that in some black groups, up to 80% of participants may prefer thinner body figures. One study 55 reported that the majority of young women in one university campus in Nigeria prefer slimmer figures, even when of normal size. These studies cited above mainly involved elites attempting to lose weight for health/beauty reasons and were in settings where intense media exposure was likely, unlike in the present study group 19, who were less educated and living traditionally. Together, these reports could indicate a possible cultural shift towards a more pervasive notion of beauty/health as thinner is better. Even so, it is to be noted that younger and, sometimes, older women are known to undergo a fattening process to improve appearance (as part of marriage/coming-of-age-rites, etc.) in several ethnic groups, for example, Efik, Ibani-Ijaw, Kalabari, Ogori, Boki, etc. in contemporary Nigeria 56–58.

These findings have implications for future research in raising a number of important issues of relevance to the prevention/control of hypertension. First, if the indicators of body size (BMI) and shape (WC) play such a minimal role in the variation in BP of adults in these communities, as this study strongly suggests, then it means that we do not know why the majority of those with elevated BP are those who are lean and why others, overweight, have normal BP. Second, preference for a particular body size can be a powerful motivation for weight-control behaviour in that an individual who desires a larger body size may be less inclined to lose weight. Weight-based interventions have been recommended to control/prevent hypertension. The relevance of a desire for larger body sizes as it relates to possible effects of weight reduction on individuals’ perception of body size is not clear as this is rarely monitored. Unfortunately, the cross-sectional nature of our study is a major limitation in answering these important questions including making any possible inference on causality from the present data set. To this extent, longitudinal studies are needed to investigate the interaction between indicators of body size/shape, perception of body size and BP in the absence/presence of a family history of hypertension, preferably beginning in early childhood.

In addition, our findings of the interaction between body size and BP in adult population were from only three traditional communities of the Yoruba, one of three major ethnic and linguistic groups in Nigeria, predominantly found in south-western and north–central geographic regions of the country. Nigeria is widely believed to have over 250 ethnic groups and 500 linguistic groups. For these reasons, it is not entirely clear the extent to which these findings can apply to other Yoruba groups in the same/or different regions or to other ethnic groups with distinct languages, cultures and traditions.

However, it is important to note that other independent investigators 7,8,29,30 have reported similar findings, whereby body size appears to play only a limited role in the variance of BP in rural/traditional Yoruba groups in another region. Indeed, some of these reports 38,59 indicate that in rural Yoruba communities similar to the ones we studied, where habitual exercise linked to daily living involves high energy expenditure, the role of body size in the determination of BP in adults is considerably reduced or even ceases to exist, similar to our findings in children and adolescents in the north-western region, where the increase in BP with age was less so in areas where the lifestyle was predominantly traditional/rural 60.

Finally, irrespective of these limitations, the present study strengthens our earlier conclusion 18,19 that a dominant notion of physical beauty that favourably views excess weight, as defined by the European standard, exists in this group. The data also showed that body size and/or its perception contributed towards the variance in BP between individuals, but only nominally so. Consequently, if these observations are confirmed in longitudinal studies, they could alter the standard view that a large body size or an increasing body size is fundamental to the increasing incidence of hypertension in Nigeria, at least in some traditional groups.


A substantial part of the work was carried out during a sabbatical leave in Niger Delta University in Wilberforce Island, Bayelsa State, Nigeria. We thank Drs P.M. Kolo, A.D. Chijioke, H.O. Sholagberu and S.A. Adebisi for their help in organizing the logistics that facilitated field work and data acquisition. The study was partly funded by a small grant from the University of Ilorin Teaching Hospital.

This work is dedicated with gratitude to Marie Lindquist, PhD, for her untiring efforts in advancing pharmacovigilance for better treatment outcome in several developing countries including Nigeria.

E.O. Okoro conceptualized and designed the study with B.A. Oyejola, who also analysed the results. Data interpretation was carried out by E.O. Okoro, E.N. Etebu and B.A. Oyejola. Dr E.N. Etebu wrote the initial draft, which was reviewed by E.O. Okoro. Thereafter, all authors read the material and made critical inputs to the final manuscript.

Conflicts of interest

There are no conflicts of interest.


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blood pressure; body size; body size perception; Nigerians

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