Is There a Relationship Between Body Mass Index (BMI) and Blood Pressure?

Ashley M. Synyard, Nicholas B. Jones, and Dr. Evan S. Fiedler

Abstract
The BMI and blood pressure of randomly selected anatomy and physiology
students at College of the Albemarle was collected over a two-year span. Statistical
analyses were completed when the total number of subjects exceeded the average of 15%
of the sample population. The results demonstrated there was not a direct correlation
between BMI and blood pressure.

Body Mass Index (BMI)

Body mass index (BMI) is a categorization of body fat (underweight, normal,
overweight, and obese) that is determined by measuring your weight relative to your
height. BMI is used as a screening tool to indicate whether a person is a healthy weight
for their height. BMI is not accurate enough to be used as a diagnostic tool, therefore
BMI can only be used as a screening tool. However, if a person's BMI is not in the
healthy BMI range, their health risks may increase exponentially (BMI, 2017).
The ranges of BMI are as follows: underweight: less than 18.5, normal weight:
18.5 to 24.9, overweight: 25 to 29.9, and obese: 30 or more. (Normal weight ranges,
2017). For example, using the calculator on the National Heart, Blood, and Lung
Institutes website an adult over 20 years of age who is 51 and 150 lbs. would have a
BMI of 28.3 which would put the person in the overweight category. Having a BMI in
the overweight or obese category may increase the risk of developing: type 2 diabetes,
heart disease, stroke, cancer, sleep apnea, osteoarthritis, fatty liver disease, kidney
disease, and/or complications during pregnancy. In contrast, being underweight is also
connected to potential issues such as nutrient deficiencies, weakened immunity, and
women are 72 % more likely to have a miscarriage if they have a low BMI just prior to
becoming pregnant (Paula , 2016).
BMI has been used for decades in population studies, by doctors and health care
professionals when deciding whether their patients are overweight (Nordqvist, 2013).
However, BMI does not measure body fat directly. Muscle and bone are denser than fat,
so an athlete or more muscular individual may have a high BMI, yet not have too much
fat. Although an athlete would score high on the BMI scale, they would not have the
same body fat as an average person with a high BMI. But most people are not lean
athletes, so BMI is a utilized indicator of their level of body fat (Why use BMI, 2016).
Although there are other means of measuring a persons body fat to weight ratio, the BMI
chart or calculator gives a general idea of body fat content for the average person. The
calculator or chart does not require a professional to do the calculation. A person can
have a sense of where they are in relation to their body fat to weight ratio, and if they are
concerned a licensed professional can perform further evaluation to indicate any risks the
person may have.
The accuracy of BMI as an indicator of body fatness appears to be higher in
persons with higher levels of BMI and body fatness. Essentially, if you are on the higher
end of the BMI scale, the likelihood of having a high percentage of body fat is high.
While a person with a very high BMI is very likely to have high body fat, a relatively
high BMI can be the results of either high body fat or high lean body mass (muscle and
bone). Ideally, a trained healthcare provider should perform appropriate health
assessments to evaluate an individual's health status and risks (Paula, 2016).
In children, the BMI is a very accurate indicator of fat content. The Centers for
Disease Control and Prevention (CDC) has developed standard growth charts for boys
and girls ages 2-20 that show the distribution of BMI values at each age. By the CDC
definition, a child whose BMI falls between the 85th and 94th percentile for age and
gender is considered overweight. A child whose BMI is at the 95th percentile or higher
for their age is considered obese. The percentile means that 95% of the children in that
age group were at or below that weight.
Some researchers have argued that BMI should be discarded in favor of other
measures, such as waist circumference. However, BMI is easier to determine, has a long
history of use, and may predict disease risk (Why use BMI, 2017).
Although, there is discrepancy in which measure is best, the BMI chart has
accurately determined disease in the average person (not a bodybuilder or athlete) and
has been used for many years and is likely to continue to be the screening tool in
healthcare. BMI can be used for population assessment of overweight and obesity.
Because the calculation for BMI only requires height and weight, it is inexpensive and
easy to use for doctors and researchers, as well as the public. BMI can be used as a
screening tool for body fatness but is not a diagnostic test (About adult BMI, 2015). In
adults, measuring both BMI and waist circumference may be better at predicting
someones weight-related risk. In children, however, there is not enough data for waist
circumference, so BMI-for-age is probably the best measure to use (Why use BMI,
2017).

Blood Pressure
Blood pressure is measured in two numbers. The first number (or top number) is
Systolic blood pressure. Systolic blood pressure indicates how much pressure your blood
is exerting against your artery walls when the heart beats. The second number (or bottom
number) is diastolic blood pressure. Diastolic blood pressure indicates how much
pressure your blood is exerting against your artery walls while the heart is resting
between beats. Typically, people are more concerned with systolic blood pressure as a
major risk factor for cardiovascular disease. In most people, systolic blood pressure rises
steadily with age due to the increasing stiffness of large arteries, long-term build-up of
plaque and an increased incidence of cardiac and vascular disease (Understanding blood
pressure readings, 2017 ).
Blood pressure is measured using a sphygmomanometer. Normal blood pressure
is when systolic blood pressure is below 120 mm Hg (millimeters of mercury), and
diastolic blood pressure is below 80 mm Hg (on average). Pre-hypertension is 120/80 mm
Hg or higher but below 140/90 mm Hg. If you have pre-hypertension, you are at risk for
developing high blood pressure. High blood pressure (hypertension) is when systolic
blood pressure is 140 mm Hg or higher or diastolic blood pressure is 90 mm Hg or higher
(Blood pressure measurement, 2017).
Hypertension gradually increases the pressure of blood flowing through your
arteries. Thus, you might experience damaged arteries as well as a possible aneurysm.
Your heart pumps blood throughout the body. High blood pressure that is uncontrolled
can cause damage to your heart in numerous ways including but not limited to coronary
artery disease, enlarged left ventricle, and heart failure. Hypertension also affects the
brain by increasing the risk of transient ischemic attack (TIA), stroke, dementia, and mild
cognitive impairment (High blood pressure dangers, 2017).

Methodology
Human Anatomy and Physiology students were given a Health o meter digital
scale in the classroom to weigh themselves, and a Prestige Medical Sphygmomanometer
to measure their blood pressure. The measurements were put into a calculator provided
on the NIH website. Each student then documented their BMI and blood pressure via an
online survey. The survey consisted of several different categories. Each category
identified their gender and had a range of Body Mass Indices and blood pressure
measurements. The student selected which category their measurements fell into. The
students did not have access to and/or knowledge of the data of other students.

Survey Categories:
Under 40, F, BMI=18.5-24.9, BP<120/80
Under 40, F, BMI=25-29.9, BP<120/80
Under 40, F, BMI=>30, BP<120/80
Under 40, F, BMI=18.5-24.9, BP=120-139/80-89
Under 40, F, BMI=25-29.9, BP=120-139/80-89
Under 40, F, BMI=>30, BP=120-139/80-89
Under 40, F, BMI=18.5-24.9, BP=>140/90
Under 40, F, BMI=25-29.9, BP=>140/90
Under 40, F, BMI=>30, BP=>140/90
Over/= 40, F, BMI=18.5-24.9, BP<120/80
Over/= 40, F, BMI=25-29.9, BP<120/80
Over/= 40, F, BMI=>30, BP<120/80
Over/= 40, F, BMI=18.5-24.9, BP=120-139/80-89
Over/= 40, F, BMI=25-29.9, BP=120-139/80-89
Over/= 40, F, BMI=>30, BP=120-139/80-89
Over/= 40, F, BMI=18.5-24.9, BP=>140/90
Over/= 40, F, BMI=25-29.9, BP=>140/90
Over/= 40, F, BMI=>30, BP=>140/90

Under 40, M, BMI=18.5-24.9, BP<120/80

Under 40, M, BMI=25-29.9, BP<120/80
Under 40, M, BMI=>30, BP<120/80
Under 40, M, BMI=18.5-24.9, BP=120-139/80-89
Under 40, M, BMI=25-29.9, BP=120-139/80-89
Under 40, M, BMI=>30, BP=120-139/80-89
Under 40, M, BMI=18.5-24.9, BP=>140/90
Under 40, M, BMI=25-29.9, BP=>140/90
Under 40, M, BMI=>30, BP=>140/90
Over/= 40, M, BMI=18.5-24.9, BP<120/80
Over/= 40, M, BMI=25-29.9, BP<120/80
Over/= 40, M, BMI=>30, BP<120/80
Over/= 40, M, BMI=18.5-24.9, BP=120-139/80-89
Over/= 40, M, BMI=25-29.9, BP=120-139/80-89
Over/= 40, M, BMI=>30, BP=120-139/80-89
Over/= 40, M, BMI=18.5-24.9, BP=>140/90
Over/= 40, M, BMI=25-29.9, BP=>140/90
Over/= 40, M, BMI=>30, BP=>140/90

Analysis
Considering an elevated BMI may be indicative of potential health issues and an
elevated blood pressure is a definitive cause of health issues, the null hypothesis is that
BMI and blood pressure are not correlated. The alternative hypothesis is that their values
are related or correlated.
Given the dataset of 96 females under 40 years of age polled for Body Mass Index
(BMI) and blood pressure, each person was categorized under three different levels of
blood pressure and three different levels of BMI. Numbers were assigned to the
categories. Normal blood pressure and Normal BMI was assigned the number one.
Overweight BMI and prehypertension was assigned the number 2. Obese BMI and
hypertension was assigned the number 3.
The first question is how strong of a correlation exists between the different data
categories. In the analysis, the BMI vs. blood pressure categories had a correlation of 0,
which meant by themselves there was no correlation. A test of correlation between the
number of students in each category and the blood pressure categories showed a
correlation of -0.5769, still not a strong relationship. The test between the number of
students and body mass index categories showed a correlation of -0.29998, an even
weaker correlation.
The program Mathematica provides a 3D visual and preserves the three by three
categories of body mass index and blood pressure, such as (1, 1, 40) = (normal body mass
index, normal blood pressure, forty students).

BMI and Blood Pressure, Women under 40 years old

BMI BP Number of Students

1 1 40
1 2 0
1 3 9
2 1 19
2 2 1
2 3 4
3 1 12
3 2 3
3 3 8

Statistic P-Value
Mardia Combined 12.174 0.202369
 When put in Mathematica and tested against a Mardia Combined test for a multi-
normal distribution, the p-value of 0.202369 allows rejection of the correlation between
the body mass index and blood pressure (p-value of 20% is not greater than 50%).
Therefore, half of the data does not follow the distribution. Considering the fact that
twenty percent implies only a fifth of the data could possibly follow the distribution, then
the BMI-blood pressure relationship is rejected at the 5% level.
However, the Mardia analysis method could be interpreted as limited relying on
the idea of quantitative data and a multi-variate method. Therefore, a more reliable
method was needed. Hence, a chi-squared distribution test was performed to determine a
correlation between qualitative categorical data. The tabulated data below displays totals
for each category for women under 40 years old:

Observed Normal (BP) Prehypertension Hypertension Total

Normal (BMI) 40 9 0 49
Overweight 19 4 1 24
Obese 12 8 3 23
Total 71 21 4 96

Next, the expected values were found. An expected value is the probability or
proportion of the total of that row with the whole total times the total for that column. For
example, the calculation with normal BMI and normal blood pressure = 71 x (49/96) to
find the expected value. The tabulated data below shows the data that was found when
finding the expected values for each category.

Expected Normal Prehypertension Hypertension Total

Normal 36.23958333 10.71875 2.041666667 49
Overweight 17.75 5.25 1 24
Obese 17.01041667 5.03125 0.958333333 23
Total 71 21 4 96

The test statistic for a chi-squared is found by the equation:

Aij is the observed value and Eij is the expected value. Therefore, the Normal with
Normal position test statistic would be found by:
(4036.2396)2
= 0.390201
36.2396

And the test statistic table would follow:

Test Statistic Normal Prehypertension Hypertension Totals
Normal 0.390201328 0.275601312 2.041666667 2.707469307
Overweight 0.088028169 0.297619048 0 0.385647217
Obese 1.475817706 1.751746894 4.349637684 7.577202285
Total 1.954047203 2.324967254 6.391304351 10.67031881
The degrees of freedom (# of rows minus 1) times (# of columns minus 1),
implies (3-1) (3-1), which is two times two, equaling four.
Referring to a chi-squared table:
9.49 < 10.6703 < 13.28, and the p-value would be 0.05 > p > 0.01.
Using MS Excel, the p-value is approximately 0.0305. The probability of the two being
correlated is low since the test statistics equated to a large number. A high value of 2 is
an indicator of independence. As can be seen from the formula, 2 is always positive or
0, and is 0 only if Aij = Eij for every i,j.

Using the following equation to find the residuals (setting them up in a normal
distribution):

=
(1 ) (1 )

Setting up the residuals in a Normal distribution with mean 0 and standard deviation of 1:
Residuals Normal Prehypertension Hypertension Totals
Normal 1.749430409 -0.555569432 -2.086031247 -0.892170271
Overweight 0.671345087 -0.712696645 0 -0.041351558
Obese -2.729959262 1.449577682 2.443106677 1.162725097
Total -0.309183767 0.181311605 0.35707543 0.229203267

Most numbers are between 1 and 2 deviations away from being the expected
values. The normal BMI and the normal blood pressure is almost 2 deviations out. The
normal BMI and the hypertension level of blood pressure is over two deviations below
what is the expected value. The obese BMI and the normal blood pressure is almost 3
deviations below what is the expected value and the obese with hypertension is
approximately 2.5. An interesting trend in the data is the totals get close to the mean of
zero which would imply no difference between the observed and expected values. The
1
margin of error, found by , is a one divided by square root of 96 which is 0.102 and

therefore there is a margin of error of 10.2% and still in that realm of less than 10 percent.
The men under 40 data set only had seven data points, many of the categories
were zero and none of them were greater than five. The low values are not well suited for
a chi-squared test. When tested in Mathematica, there was still less than five percent
correlation using the Mardia combined test.
However, combining the two sets (men and women under 40 years old) provided
enough data for a chi-squared test.
 Observed Normal Prehypertension Hypertension Totals
Normal 45 11 0 56
Overweight 19 4 1 24
Obese 12 8 3 23
Total 76 23 4 103

Expected Normal Prehypertension Hypertension Totals

Normal 24.46601942 12.50485437 2.174757282 56
Overweight 17.70873786 5.359223301 0.932038835 24
Obese 16.97087379 5.13592233 0.893203883 23
Total 76 23 4 103

Test Statistic Normal Prehypertension Hypertension Totals

Normal 17.23387656 0.181096605 2.174757282 19.58973045
Overweight 0.094154531 0.344730547 0.004955502 0.44384058
Obese 1.455999645 1.597169967 4.96929084 8.022460452
Total 18.78403074 2.122997119 7.149003624 28.05603148

With a test statistic of 28.056 and 4 degrees of freedom, the p-statistic is P < 0.001 since
28.056 > 18.47. Using Excel, the approximate p-value is 1.215 105 . This small
percentage shows there is not much correlation at all. The test statistic implies that the
expected values and the observed values are highly deviated from each other. With the
large differences, the conclusion of the two not being correlated can be established.

The residuals in a normal distribution:

Residuals Normal Prehypertension Hypertension Totals

Normal 12.00322377 -0.7148229 -2.226773762 9.06162711
Overweight 0.684325006 -0.760709027 0.081987925 0.005603903
Obese -2.674182139 1.627132072 2.580012689 1.532962622
Total 10.01336664 0.151600145 0.435226852 10.60019363

These findings (again) show the data set exceedingly deviated from the expected
values. The normal BMI and normal blood pressure show a very large deviation from the
mean of zero, giving credence to the idea that a person with a normal BMI should have a
normal blood pressure. All the other categories are under one deviation or over two
deviations, showing there is not a correlation between BMI and blood pressure.

Discussion
As a whole, the data supports a conclusion of accepting the null hypothesis that
BMI and blood pressure are not correlated. As blood pressure went up the probability of
having a high BMI did not go up (and vice versa). The two values that were shown to be
consistent when together were normal BMI with normal blood pressure. If BMI is to be
continued to be utilized in the healthcare field as a screening tool, further study of its
relationship to proven diagnostic measures would be recommended.
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 Acknowledgements

The BMI and blood pressure research project was completed by support from an
anonymous component fund of the North Carolina Community Foundation. Ashley
Synyard has earned an associates in General Education and is currently pursuing an
associates degree in Nursing at College of The Albemarle. Nicholas Jones is an Applied
Mathematics graduate student at Elizabeth City State University, which is where he
earned a bachelors degree in Mathematics. He is concurrently a student at College of
The Albemarle where he is studying Computer Technology Integration with Computer
Programming. Dr. Evan S. Fiedler is an Assistant Professor in Anatomy and Physiology,
Biology, and Microbiology at College of The Albemarle.