Weight Loss and Blood Pressure Control (Pro)David W. Harsha, George A. Bray

Overweight is an increasingly prevalent conditionthroughout the world. Current estimates, which are

probably conservative, indicate that at least 500 000 000people worldwide are overweight as defined by a body massindex (BMI) of between 25.0 and 29.9 and an additional250 000 000 are obese with a BMI of 30.0 or higher.1 In theUnited States, recent data indicate that as much as 66% of theadult population is overweight or obese.2

Overweight and obesity are established risk factors forcardiovascular disease (CVD), stroke, noninsulin dependentdiabetes (NIDDM), certain cancers, and numerous otherdisorders.3,4,5,6,7 It is also a risk factor for hypertension.8

Hypertension, defined as a systolic blood pressure inexcess of 140 mm Hg or a diastolic blood pressure higherthan 90 mm Hg, is also a globally increasing public healthconcern. Roughly 1 billion individuals worldwide are esti-mated to exhibit clinically significant elevated blood pressurewith about 50 million of those residing in the United States.8

Hypertension, in turn, is associated with increased risk forCVD, stroke, renal disease, and all-cause mortality.9,10,11,12

The JNC VII report defines Stage 1 hypertension as bloodpressure levels between 140 and 159 mm Hg systolic and 90and 99 diastolic. Additionally, the report establishes a cate-gory of Prehypertension (Systolic blood pressure between120 and 140 mm Hg or diastolic between 80 and 89 mm Hg).These 2 blood pressure classifications are deemed to beappropriate primary targets for lifestyle modification inter-ventions, including weight loss. Higher levels of bloodpressure, or stage 1 hypertension that is maintained over along period, should be addressed primarily with medicationsor other physician directed treatments.

There is a positive relationship between overweight orobesity and blood pressure and risk for hypertension. As earlyas the 1920s, a significant association between body weightand blood pressure was noted in men.13,14 In the interveningyears, epidemiological studies have routinely confirmed thisassociation. The Framingham Study found that hypertensionis about twice as prevalent in the obese as the nonobese ofboth sexes.15 Stamler and colleagues16 noted an odds ratio forhypertension of obese relative to nonobese (BMI of less than

25) of 2.42 for younger adults and 1.54 for older ones. TheNurses Health Study17 compared women with BMIs of lessthan 22 with those above 29 and found a 2- to 6-fold greaterprevalence of hypertension among the obese.

More recent data from the Framingham Study furthersupport this relationship. Divided into BMI quintiles, Fra-mingham participants of both sexes demonstrated increasingblood pressures with increased overweight. In this instancethose in the highest BMI quintile exhibited 16 mm Hg highersystolic and 9 mm Hg higher diastolic blood pressures thanthose in the lowest quintile. For systolic blood pressure thistranslated into an increase of 4 mm Hg for each 4.5 kg ofincreased weight.18 In younger Canadian adults, Rabkin etal19 noted a 5-fold greater incidence of hypertension inindividuals with BMIs of more than 30 relative to those lessthan 20 for both sexes.

The public health burden of hypertension is certainlyenormous. Although perhaps impossible to tease out becauseof associations with other risk factors, including overweight,hypertension is clearly a major contributor to most categoriesof chronic disease.20 Diseases of the heart and cerebrovascu-lar diseases are the 1st and 3rd major causes of mortality inthe United States accounting for more than 1/3 of all deathsannually.21 Hypertension is one of the clearest risk factors forboth of these causes of death.8 Therefore, reduction inhypertension constitutes a major health goal for the immedi-ate future. The federal government through the HealthyPeople 2010 initiative proposes to increase to 50% those inthe adult hypertensive population with controlled hyperten-sion.22 This contrasts with the currently estimated figure of34%.8

Blood pressure control, the return of blood pressure tonormotensive status, would have significant impact on mor-tality from heart and cerebrovascular diseases. In clinicaltrials antihypertensive therapy can result in reductions ofincidence of stroke, myocardial infarction, and heart failureof between 20% and 50%.23 Ogden et al2 estimate that a12-mm Hg decline in systolic blood pressure maintained overa period of 10 years in a population with initial stage 1hypertension will reduce incident mortality by between 9%

The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.From the Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge.Correspondence to David W. Harsha, Pennington Biomedical Research Center, Louisiana State University System, 6400 Perkins Road, Baton Rouge,

LA 70808. E-mail david.harsha@pbrc.edu(Hypertension. 2008;51:1420-1425).© 2008 American Heart Association, Inc.

Hypertension is available at http://hyper.ahajournals.org DOI: 10.1161/HYPERTENSIONAHA.107.094011

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and 11%. A population wide reduction of 5.5 mm Hg systolicor 3.0 mm Hg diastolic would result in an estimated 15%decline in incident coronary heart disease and a 27% declinein stroke.24,25

The challenge, therefore, is how to accomplish this goal.Numerous treatments have proved efficacious, at least in theshort term, in clinically significantly reducing blood pressurelevels.8 Of these, weight loss offers a number of attractivefeatures. We will consider the evidence for weight lossmediated reductions in blood pressure accomplished throughthe more traditional means of caloric restriction and otherlifestyle modification strategies. We will not review the dataassociated with weight loss resulting from pharmacologicalor surgical interventions except as it may relate to mainte-nance of weight loss.

Blood pressure alteration is theorized to be positivelyassociated with weight change. Although a number of studieshave examined this from a perspective of weight loss andreduction in blood pressure, there are little data in humans toinform directly the idea that increase in weight relates toincreased blood pressure at the individual level. Animalstudies have been the principle source of this information.Rocchini et al26 noted significant increases in blood pressureaccompanying weight gain from overfeeding in dogs. Hall etal27 have confirmed this relationship.

On the other hand, numerous clinical interventions inhumans have examined the relationship of weight loss toblood pressure change. Haynes28 reviewed 6 clinical trialsavailable to that time relating weight loss and blood pressure,noting that 3 of them showed a significant impact of weightloss whereas the other 3 did not demonstrate a clear impact.More recently, a meta-analysis of 25 studies on this topic wasperformed by Neter et al.29 The authors concluded that a 1-kgloss of body weight was associated with an approximate1-mm Hg drop in blood pressure. Further this blood pressurereduction was accomplished without the necessity of alsoattaining normal weight status. The Trial of HypertensionPrevention (TOHP), one of the largest of these studies,included a weight loss intervention arm.30 In this instance, a2-kg loss in weight over a 6-month period resulted in adecline of 3.7 mm Hg in systolic and 2.7 mm Hg in diastolicblood pressure. In addition, a 42% decline in the instance ofhypertension was noted on this sample.31

Another analysis of multiple clinical trials of blood pres-sure reduction was conducted by Ebrahim and Smith.32 In thisreport, 8 trials were examined for the effects of weight loss onblood pressure and concluded that weight gain was associatedwith increased blood pressure whereas weight loss resulted inreduced blood pressure. Blood pressure reductions were onthe order of 5.2 mm Hg both systolic and diastolic for varyingdegrees of weight reduction.

Given the established association between weight changeand blood pressure status, the question arises as to how thisinteraction functions physiologically. Rocchini33 identifiesnumerous potential biological mechanisms by which weightloss or fat loss might lead to parallel declines in bloodpressure. Among them are reductions in insulin resistance,enhanced sodium retention, alterations in vascular structureand function, changes in ion transport, enhanced stimulation

of the rennin-aldosterone-angiotensin system, increased acti-vation of sympathetic nervous system, and changes in natri-uretic peptide. The wide range of potential mechanisms alsomay be a major factor in accounting for the apparentheterogeneity in blood pressure response to any treatment.Weight loss may variably and simultaneously impact one ofmore of these proposed routes of action. Because weightstatus itself is a result of multiple causes, the fashion in whichit induces blood pressure change would not surprisingly bevariable.

Examination of these possible mechanisms raises oneimportant caveat about recommending weight loss for bloodpressure control. This is the possibility that the effects ofweight loss are mediated through some other system and thatweight loss might not be an independent influence on bloodpressure status.

Because most weight loss is accomplished through dietarymanipulation, it is possible that some aspects of diet, whenaltered, are the true determinants of blood pressure reduction.

Chief among perceived dietary influences on blood pres-sure is sodium consumption. A large literature supports thenotion that decreasing sodium consumption below that typi-cal in Western society will result in a decline of bloodpressure. Numerous epidemiological studies have demon-strated this relationship.34,35,36 Reductions in sodium intakeon the order of 75 mmol/d or less have been associated witha decline in blood pressure of about 1.9 mm Hg systolic and1.1 diastolic.36 The previously mentioned Trial of Hyperten-sion Prevention found that a decrease of 44 mmol/d ofsodium led to a 38% reduction in the incidence of hyperten-sion in one of its treatment arms.30 The previously cited groupanalysis by Ebrahim and Smith32 found a pooled reduction of2.9 and 2.1 mm Hg blood pressure level with varying degreesof sodium restriction. The Dietary Alterations to Stop Hyper-tension Study (DASH-Na) found a maximum reduction ofabout 6.7 mm Hg systolic and 3.5 diastolic in blood pressurewith an approximate 100-mmol/d reduction in sodium intakein those with elevated blood pressure on a typical Americandiet. An approximate 50 mmol/d reduction in sodium con-sumption led to a blood pressure decline of 2.1 and1.1 mm Hg systolic and diastolic.37 These findings wereproduced in the absence of weight loss.

The jury of scientific opinion is still out on the degree towhich weight loss or sodium restriction make independentcontributions to blood pressure reduction. An early study,Dahl et al38 found sodium restriction in low calorie diets to bethe primary cause of blood pressure reduction. This is also thefinding of Fagerberg et al.39 Several more recent studies havesided with weight loss as having an independent effect onblood pressure reduction. Reisen et al40 found blood pressurereductions on the order of 3 mm Hg for each kg of weight lossin a sample of hypertensive men with no sodium restriction.Tuck et al41 and Maxwell et al42 additionally reported sodiumindependent effects of weight loss in a sample of hyperten-sive men as well.

Other dietary constituents have been implicated in thecontrol of blood pressure as well. Vegetarian diets are widelyassociated with lower blood pressure levels.43 The DietaryApproaches to Stop Hypertension Trial25 demonstrated that a

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diet high in fruit, vegetable, and low-fat dairy servings couldreduce blood pressure by 5.3 and 3.0 mm Hg systolic anddiastolic blood pressure, respectively, in the absence of eitherweight loss or sodium restriction. Raben et al44 found thatsignificantly increased sucrose consumption led to notewor-thy increases in both weight and fat mass as well as increasesin blood pressure on the order of 4 mm Hg.

Likewise, physical activity has been shown to influenceblood pressure levels and is additionally a part of therecommended regimen of weight loss strategies.8 Bouchard etal45 examined the pertinent studies to that time and concludedthat approximately 1 hour per day of low to moderate levelphysical activity could support weight loss but that such aprogram would require several years to be completely effec-tive. Ebrahim and Smith32 studied 8 clinical trials in whichexercise was a primary component in blood pressure reduc-tion. They found modest impacts on blood pressure reductionof 0.8 to 3.7 and 0.2 to 1.0 mm Hg resulting from primarilylow levels of physical activity. A meta-analysis of the effectsof physical activity on blood pressure conducted by Kelley etal46 led the authors to predict a decline in systolic bloodpressure of 3 to 5 mm Hg associated with moderate physicalactivity. Whelton et al47 reported a meta-analysis of normo-tensives with significant reductions in blood pressure atten-dant to a variety of types of physical activity. Interestingly,although there appears to be consensus among these investi-gators that increased physical activity drives somewhat largerdeclines in blood pressure, the nature of this relationship isunclear. Although there might be a dose response relationshipin the largest sense, most of these studies examine the impactof low to moderate physical activity and therefore have a capon the degree they are capable of examining the full impact ofexercise on blood pressure.

Because weight loss cannot be accomplished in the ab-sence of some combination of dietary or physical activitybehaviors, separating independent effects of each componenton blood pressure is extremely challenging. It is clear,however, that weight loss, regardless of how obtained, isassociated with clinically significant reductions in bloodpressure.

Another issue is the extent to which maintained weight losscontinues to influence blood pressure status. The majority ofstudies linking weight loss to blood pressure reduction do soonly in the short term, usually examining impacts on a scaleof less than 1 year. The effect of longer term weight loss haspredictably been much less examined. A number of clinicaltrials have examined the issue on the scale of more than 1year.

The Premier Trial followed 810 individuals with initialelevated blood pressure or stage 1 hypertension for 18 monthsafter randomization to control or either of 2 putatively hearthealthy active interventions.48 Both active interventionscounseled an increase in physical activity, and either areduced fat and calorie diet, or a diet high in fruits, vegeta-bles, and low fat dairy servings using the DASH dietarymodel.25 Both active interventions also counseled reductionin sodium intake. Weight and blood pressure change wereobserved at baseline, at interim periods, and at the end of 18months of intervention. At the end of the trial both active

interventions saw sustained weight loss and blood pressurereduction. The active intervention without the DASH dietresulted in an average weight loss of 3.8 kg, that with theDASH diet of 4.3 kg. Mean blood pressure reductions(systolic/diastolic) were 8.6/6.0 and 9.5/6.2 mm Hg for thesame intervention arms, respectively. Urinary sodium reduc-tions were 18.4 and 24.5 mmol/d, respectively, for each groupas well.

The Trial of Hypertension Prevention examined 181 par-ticipants for weight loss or sodium reduction and bloodpressure for 7 years of follow-up.49 The sample was randomlyassigned to a nontreated control, a sodium reduction, or aweight loss arm. The active component of the interventionlasted 18 months but individuals were further monitored forblood pressure, weight, and dietary status for 7 years. Incidenthypertension was the outcome variable of interest. Theweight loss group in the absence of sodium restriction, whichhad an average reduction of 5 kg in weight at 18 months,30

demonstrated an incidence of hypertension of 18.9% after 7years. This contrasts with the sodium reduction in the absenceof weight loss group which found an incidence of hyperten-sion of 22.4% over the same period. These results were foundin spite of the fact that much of the weight in the weight lossgroup had been regained at year 7.

The Hypertension Prevention Trial followed 841 individ-uals for up to 3 years in caloric restriction/weight loss,sodium reduction, caloric restriction and sodium reduction,and sodium reduction and increased potassium interventionarms.50 At 3 years of follow-up, the caloric restriction grouphad maintained weight loss about 4% of baseline and dem-onstrated a 5.1/2.4-mm Hg reduction in blood pressure. Theother dietary interventions resulted in smaller amounts ofblood pressure reduction. The authors recommend caloricrestriction and accompanying weight loss as the strategy ofchoice in influencing blood pressure.

Most recently the Weight Loss Maintenance program hasreleased its findings.51 In this instance, 1083 participants whohad previously lost 8.5 kg or more were enrolled in aself-directed control or 1 of 2 treatment arms for study ofweight status over a 30-month period. Although all 3 groupsexhibited some regain over this time, all maintained at leastabout 3 kg of weight loss. One arm, a monthly personalcontact group, maintained a larger 4.5-kg weight loss. Alllevels of maintained weight loss would result in significantreductions in blood pressure in the general population.

Several other smaller scale studies have documented apositive association between weight loss maintained forperiods of up to 2 years and reduced blood pressure.52,53,54 Insum, it is clear that weight loss reduces blood pressurereduction and that the blood pressure benefits are retainedover at least the short to midperiod, particularly in those whomaintain the weight loss.31

The effects over longer time frames are less clear. Sjostromet al55 report 8 years of follow-up on the relationship ofweight loss to blood pressure in a group 1157 obese partici-pants who received gastric bypass surgery to induce weightloss. Initial weight losses of 18% of presurgical body weightwere associated with a decline in blood pressure of about12 mm Hg systolic and 8 mm Hg diastolic. Over a 6- to

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8-year period, weights increased only very slightly in thisgroup whereas blood pressure levels rebounded and, at theend of the study, were similar to or higher than untreatedcontrols. The authors themselves, however, are skeptical thatthis is a generalizeable finding pointing to methodologicaland analytic inconsistencies in their sample.56 It remains forother research examining maintained weight loss.

Taken in its totality, it is clear that weight loss is associatedwith a decline in blood pressure at least in the short andmidterm. These findings extend even to those initially in thenormotensive range and hold for both genders and all ethnicgroups examined. This conclusion is endorsed by the JNC VIIexpert panel and has become a part of the suggested lifestylearmamentarium in combating hypertension.8 Undoubtedly,much of the attractiveness of suggesting weight loss stemsfrom its multipurpose healthy nature. Not only is weightreduction associated with improved blood pressure controlbut it confers benefits in the management of many otherdisorders including Type II diabetes, musculo-skeletal disor-ders, some cancers, and other health concerns including allcause mortality.3,4,5,6,7

Nevertheless, using weight loss as sole means of accom-plishing blood pressure control is not without problems. Chiefamong these is the difficulty involved with achieving andmaintaining optimal weight. Most who attempt weight lossachieve little in this regard, and most who are initiallysuccessful rebound to their early status or higher.57,58,59 In thegrimmest scenarios, the net result is not only a population atincreased biomedical risk but also suffering from a number ofpsycho-social insults resulting from these failures.60 Never-theless, weight loss is successfully accomplished and ismaintained by a significant percentage of those who attemptusing only lifestyle modifications.61 The methods and strate-gies used are still developing and, if careful attention is paidto refining them, the result will undoubtedly be improvementin those achieving weight loss and a decline in recidivism.62

Maintenance of weight loss remains the challenge. Wing andPhelan61 report that approximately 20% of those attemptingweight reduction via lifestyle modification are successful atlong term weight control. Research into the mechanisms bywhich these results are obtained should increase these successrates. It should be noted that the impact of weight loss onblood pressure does not require achievement of optimalweight (BMI �25.0). Smaller decrements of weight lossclearly are of clinical significance in controlling blood pres-sure levels. Likewise, complete maintenance of weight loss isnot necessary in this regard. Some recidivism in weigh loss isnormal but, as long as weight is still below baseline level,there can be impact on blood pressure.31

An additional issue, alluded to earlier, is the degree towhich weight loss may be identified as an independentinfluence on blood pressure status. As noted weight loss, atleast via traditional approaches, can only be accomplishedthrough some combination of diet and physical activitychanges. Numerous dietary components have been identifiedas potentially impacting blood pressure, most notably sodiumintake. But increased fruit and vegetable consumption isclearly pertinent as are numerous other macro and micronu-trients.25 Physical activity, likewise, is associated with de-

creases in blood pressure level. The result is a situation inwhich it is not practicable to sort out independent causaleffects. The argument then might emerge as to whetherdietary or physical activity is a more desirable target for bloodpressure control. In these cases, however, data on recidivismare not much more encouraging.62 Adoption of the entirepackage of lifestyle changes, appropriate eating, physicalactivity, and attention to weight management, yields thegreatest likelihood of success.48,61 Overweight and obesity arebest seen in this light as an ongoing major risk factor forhypertension, requiring life-long surveillance for both andimmediate treatment as indicated by physician review.

And, at least in the case for blood pressure management,the bar may not be so high as for overall success in weightloss. Data clearly show that modest reductions in weight canhave an impact on blood pressure.20,29,63 Weight loss in therange of 2 to 4 kg are associated with systolic blood pressuredeclines in the range of 3 to 8 mm Hg, a clinically significantimpact.30,31,32,48,49 Additionally, these impacts are felt rapidlyas weight is lost usually within a few weeks48 and appear tome maintained, with corresponding maintenance of weightloss, for periods of at least 18 months to 3 years.49 Data onlong term maintenance of weight loss are still to be produced.Such studies are, clearly, both expensive and, by definition,time consuming. Emerging information from such programsas the Weight Loss Maintenance study,51 however, yieldsome confidence that, through appropriate treatment includ-ing lifestyle modification, weight can be lost and kept off.

Perhaps the largest problem with weight reduction as theprimary mechanism for blood pressure control is that it isethically appropriate only for those with stage 1 hypertensionor less. Clinical considerations require drug or other moreintensive interventions in those with more elevated bloodpressures. Nevertheless, those in the prehypertensive andstage 1 hypertensive range constitute about 95 to 100 millionAmericans, about 40% of the adult population.64 This demo-graphic is a very large target for weight loss intervention, andone that has the potential for considerable public healthimpact.

In conclusion, weight loss is clearly associated with adecrease in blood pressure as well as numerous other im-provements in biomedical status. Its accomplishment is donesuccessfully as the major component of a spectrum ofappropriate lifestyle modifications. Strategies for achievinglong-term weight loss are emerging, and the proportion ofthose who are successful is growing. As a major public healthissue, the management of overweight is of the highest priorityand is receiving major support from the federal governmentand other institutions. Successfully accomplishing nationalgoals for weight management can supply additional benefitsin the reduction of blood pressure and the associated biomed-ical burden of risk for CVD and stroke.

Sources of FundingSupported by Lower Mississippi Delta Nutrition and Health Initia-tive (USDA Grant No. 58-0101-5-018, Amendment 1).

DisclosuresNone.

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Response to Weight Loss and Blood Pressure Control: The Pro SideAllyn L. Mark

Harsha and Bray argue that diet and behavioral modification produce significant and sustained weight loss and that thismodest diet-induced weight loss diet is effective in treating mild hypertension. I remain unconvinced and deeply skepticalon both points. I refer the reader to my companion article in this issue and to my recent article “Weight reduction fortreatment of obesity-associated hypertension: nuances and challenges” in Current Hypertension Reports (2007;9:368–372).Harsha and Bray highlight the recent Weight Loss Maintenance trial. I’m unimpressed. Like previous trials, it shows weightregain with only modest residual weight loss. The duration of the trial was not long enough to establish sustained weightloss, and there was no measurement of blood pressure. Further, there are questions about the pragmatism of long-termwidespread lifestyle modification in the “real world.” In addition, although even modest weight loss produces an earlyreduction in blood pressure, the long-term reductions in blood pressure are much less impressive than the short termreductions. One more nail in the coffin of the idea that weight loss is the answer to hypertension in obesity is the following.In patients undergoing bariatric surgery for morbid obesity, although blood pressure decreases initially, it returns to controllevels after 6 to 8 years despite substantial and sustained decreases in body weight. In summary, chronic blood pressurereduction during dieting and weight loss is not as sustained or pronounced as generally assumed.

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David W. Harsha and George A. BrayWeight Loss and Blood Pressure Control (Pro)

Print ISSN: 0194-911X. Online ISSN: 1524-4563 Copyright © 2008 American Heart Association, Inc. All rights reserved.

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