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To investigate the association between birth size and hypertension within a genetically homogenous population of high birth weight.Cohort-study with retrospectively collected data on size at birth.The study included 4601 men and women born 1914–1935 in Reykjavik, Iceland, who participated in the Reykjavik Study of the Icelandic Heart Association.Birth size measurements, adult blood pressure (BP) and body mass index (BMI), and family history of hypertension.Birth weight was inversely related to hypertension in adulthood in women (P for trend < 0.001). The relationship was of borderline significance in men (P for trend = 0.051). A low ponderal index was significantly associated with high BP in women (P for trend = 0.025) but not men (P> 0.05). For women with an adult BMI > 26 kg/m2, the odds ratio for hypertension for those born weighing < 3.45 kg was 2.1 [95% confidence interval, 1.3–3.3, compared with women born weighing > 3.75 kg. The association was only significant in women without a family history of hypertension.An inverse association between size at birth and adult hypertension was seen in a population of greater birth size than has previously been investigated. The relation was strongest among women born small who were overweight in adulthood, and for those without a family history of hypertension. The results support the hypothesis that the association between birth weight and hypertension is not of genetic origin only. The large birth size of Icelanders might be protective and partly explain the lower mean systolic blood pressure in Iceland than in related nations.