Heart, Lung and Circulation
Original Article| Volume 24, ISSUE 6, P573-582, June 2015

South African and International Reference Values for Lung Function and its Relationship with Blood Pressure in Africans

Published:December 27, 2014DOI:


      In South Africa respiratory diseases are highly prevalent, with cardiovascular disease being a manifestation. However, international reference values for lung function are commonly used, which may not be appropriate to correctly identify reduced lung function. An inverse relationship exists between lung function and blood pressure (BP) but is not investigated extensively in black South Africans.


      We included 2010 Africans from the PURE (Prospective Urban Rural Epidemiology) study (aged > 35 years) in the North West Province. Spirometry was performed and predicted values for forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were calculated from South African, European and United States prediction equations.


      With the exception of the European predicted values, all other predicted mean FEV1 and FVC were above 80%. South African reference values displayed the highest percentages of the predicted values for FEV1 and FVC (87.9 and 99.7%, respectively.) BP increased from quintiles five to one for both FEV1 and FVC, (p for trend <0.001). After adjustment the differences remained (p<0.05).


      South African reference values yielded higher percentages of predicted FEV1 and FVC values than European and US equations suggesting that South African prediction equations may be more useful when investigating lung function in black South Africans. Elevated BP is related to reduced lung function, highlighting the importance in managing both respiratory- and cardiovascular disease.


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      1. World Health Organization. Non-communicable Diseases (NCD) Country profiles, 2014. Available at: Accessed February 25, 2014.

        • Mayosi B.M.
        • Flisher A.J.
        • Lalloo U.G.
        • Sitas F.
        • Tollman S.M.
        • Bradshaw D.
        The burden of non-communicable diseases in South Africa.
        Lancet. 2009; 374: 934-947
        • Stanojevic S.
        • Wade A.
        • Stocks J.
        Reference values for lung function: past, present and future.
        Eur Respir J. 2010; 36: 12-19
        • Louw S.
        • Goldin J.
        • Joubert G.
        Spirometry of healthy adult South African men.
        S Afr Med J. 1996; 86: 814-819
        • Mokoetle K.E.
        • de Beer M.
        • Becklake M.R.
        A respiratory survey in a black Johannesburg workforce.
        Thorax. 1994; 49: 340-346
      2. Van Schalkwyk E, Schultz C, Joubert J, White N. Guideline for office spirometry in adults, 2004;94:576–587.

        • Quanjer P.H.
        • Stanojevic S.
        • Cole T.J.
        • Baur X.
        • Hall G.L.
        • Culver B.H.
        • et al.
        Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations.
        Eur Respir J. 2012; 40: 1324-1343
        • Koegelenberg C.F.N.
        • Swart F.
        • Irusen E.M.
        Prediction equations for spirometry in South Africa.
        S Afr Med J. 2013; 103: 597
        • Barnes P.
        • Celli B.
        Systemic manifestations and comorbidities of COPD.
        Eur Respir J. 2009; 33: 1165-1185
        • Schunemann H.J.
        • Dorn J.
        • Grant B.J.
        • Winkelstein W.
        • Trevisan M.
        Pulmonary Function Is a Long-term Predictor of Mortality in the General Population. 29-Year Follow-up of the Buffalo Health Study.
        Chest. 2000; 118: 656-664
        • Bang K.M.
        • Gergen P.J.
        • Kramer R.
        • Cohen B.
        The effect of pulmonary impairment on all-cause mortality in a national cohort.
        Chest. 1993; 103: 536-540
        • Hole D.J.
        • Watt G.C.
        • Davey-Smith G.
        • Hart C.L.
        • Gillis C.R.
        • Hawthorne V.M.
        Impaired lung function and mortality risk in men and women: findings from the Renfrew and Paisley prospective population study.
        Br Med J. 1996; 313: 711-7155
        • Engstrom G.
        • Lind P.
        • Hedblad B.
        • Wollmer P.
        • Stavenow L.
        • Janzon L.
        • et al.
        Lung function and cardiovascular risk: relationship with inflammation-sensitive plasma proteins.
        Circulation. 2002; 106: 2555-2560
        • Selby J.V.
        • Friedman G.D.
        • Quesenberry Jr., C.P.
        Precursors of essential hypertension: pulmonary function, heart rate, uric acid, serum cholesterol, and other serum chemistries.
        Am J Epidemiol. 1990; 131: 1017-1027
        • Sparrow D.
        • Weiss S.T.
        • Vokonas P.S.
        • Cupples L.A.
        • Ekerdt D.J.
        • Colton T.
        Forced vital capacity and the risk of hypertension. The Normative Aging Study.
        Am J Epidemiol. 1988; 127: 734-741
        • Engström G.
        • Wollmer P.
        • Valind S.
        • Hedblad B.
        • Janzon L.
        Blood pressure increase between 55 and 68 years of age is inversely related to lung function: longitudinal results from the cohort study ‘Men born in 1914’.
        J Hypertens. 2001; 19: 1203-1208
        • Wu Y.
        • Vollmer W.M.
        • Buist A.S.
        • Tsai R.
        • Cen R.
        • Wu X.
        • et al.
        Relationship between lung function and blood pressure in Chinese men and women of Beijing and Guangzhou. PRC-USA Cardiovascular and Cardiopulmonary Epidemiology Research Group.
        Int J Epidemiol. 1998; 27: 49-56
        • Mannino D.M.
        • Ford E.S.
        • Redd S.C.
        Obstructive and restrictive lung disease and markers of inflammation: data from the Third National Health and Nutrition Examination.
        Am J Med. 2003; 114: 758-762
        • Sin D.D.
        • Man S.F.
        Why are patients with chronic obstructive pulmonary disease at increased risk of cardiovascular diseases? The potential role of systemic inflammation in chronic obstructive pulmonary disease.
        Circulation. 2003; 107: 1514-1519
        • Sin D.D.
        • Wu L.
        • Man S.P.
        The Relationship Between Reduced Lung Function and Cardiovascular MortalityA Population-Based Study and a Systematic Review of the Literature.
        Chest. 2005; 127: 1952-1959
        • Teo K.
        • Chow C.K.
        • Vaz M.
        • Rangarajan S.
        • Yusuf S.
        The Prospective Urban Rural Epidemiology (PURE) study: examining the impact of societal influences on chronic noncommunicable diseases in low-, middle-, and high-income countries.
        Am Heart J. 2009; 158: 1-7
        • Duong M.
        • Islam S.
        • Rangarajan S.
        • Teo K.
        • O’Byrne P.M.
        • Schünemann H.J.
        • et al.
        Global differences in lung function by region (PURE): an international, community-based prospective study.
        Lancet Respir Med. 2013; 1: 599-609
      3. Marfell-Jones M, Olds T, Stewart A, Carter L. International Standards for Anthropometric Assessment. Revised edition. International Society for the Advancement of Kinanthropometry; 2006.

      4. Standardization of Spirometry, 1994 Update. American Thoracic Society. Am J Respir Crit Care Med 1995;152:1107–1136.

        • Knudson R.J.
        • Slatin R.
        • Lebowitz M.
        • Burrows B.
        The maximal expiratory flow-volume curve. Normal standards, variability, and effects of age.
        Am Rev Respir Dis. 1976; 113: 587-600
        • Appay V.
        • Sauce D.
        Immune activation and inflammation in HIV-1 infection: causes and consequences.
        J Pathol. 2008; 214: 231-241
        • Koegelenberg C.F.N.
        • Swart F.
        • Irusen E.M.
        Guideline for office spirometry in adults, 2012.
        S Afr Med J. 2013; 103: 52-61
        • Ehrlich R.
        • Jithoo A.
        Chronic respiratory diseases in South Africa.
        Chronic Diseases of Lifestyle in South Africa. 1995;
        • Gan W.
        • Man S.
        • Senthilselvan A.
        • Sin D.
        Association between chronic obstructive pulmonary disease and systemic inflammation: a systematic review and a meta-analysis.
        Thorax. 2004; 59: 574-580
        • Suwa T.
        • Hogg J.C.
        • Quinlan K.B.
        • Ohgami A.
        • Vincent R.
        • van Eeden S.F.
        Particulate air pollution induces progression of atherosclerosis.
        J Am Coll Cardiol. 2002; 39: 935-942
        • Mills N.L.
        • Miller J.J.
        • Anand A.
        • Robinson S.D.
        • Frazer G.A.
        • Anderson D.
        • et al.
        Increased arterial stiffness in patients with chronic obstructive pulmonary disease: a mechanism for increased cardiovascular risk.
        Thorax. 2008; 63: 306-311