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Cited by 528Blood Pressure and Hypertension StudiesDiabetes, Cardiovascular Risks, and LipoproteinsCardiovascular Function and Risk Factors

Obesity‐Related Hypertension: Pathogenesis, Cardiovascular Risk, and Treatment: A Position Paper of The Obesity Society and the American Society of Hypertension

Open access
Landsberg, Lewis, Aronne, Louis J., Beilin, Lawrence J., Burke, Valerie, Igel, Leon I., Lloyd‐Jones, Donald, Sowers, James·2013·The Journal of Clinical Hypertension
DOI 10.1111/jch.12049PMC PMC8108268
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Abstract

In light of the worldwide epidemic of obesity, and in recognition of hypertension as a major factor in the cardiovascular morbidity and mortality associated with obesity, The Obesity Society and the American Society of Hypertension agreed to jointly sponsor a position paper on obesity‐related hypertension to be published jointly in the journals of each society. The purpose is to inform the members of both societies, as well as practicing clinicians, with a timely review of the association between obesity and high blood pressure, the risk that this association entails, and the options for rational, evidenced‐based treatment. The position paper is divided into six sections plus a summary as follows: pathophysiology, epidemiology and cardiovascular risk, the metabolic syndrome, lifestyle management in prevention and treatment, pharmacologic treatment of hypertension in the obese, and the medical and surgical treatment of obesity in obese hypertensive patients.

AI snapshot

Written from the paper’s full text.

TL;DR

This joint position paper from The Obesity Society and the American Society of Hypertension reviews mechanisms, epidemiology, cardiovascular risk, and treatment of obesity-related hypertension. It argues that obesity-related hypertension is driven largely by central adiposity, insulin resistance, sympathetic activation, RAAS activation, and salt sensitivity, and that management requires lifestyle change plus targeted pharmacologic and sometimes surgical therapy.

Key findings

  • Obesity-related hypertension is strongly linked to central obesity, insulin resistance/hyperinsulinemia, leptin, increased sympathetic nervous system activity, renin-angiotensin-aldosterone system activation, and renal sodium retention; the paper states that at least 75% of hypertension incidence is related directly to obesity.
  • NHANES 2005–2008 data show hypertension prevalence of 30.9% among US adults; by BMI, prevalence was 42.5% in obese (BMI ≥30), 27.8% in overweight (BMI 25.0–29.9), and 15.3% in BMI <25. Framingham long-term follow-up reported multivariable-adjusted relative risks for developing hypertension of 1.48 and 1.70 for overweight men and women and 2.23 and 2.63 for obese men and women, respectively.
  • Hypertension confers a 2- to 3-fold increased risk for all CVD events combined; risk for CHD and stroke mortality rises continuously from SBP 115 mm Hg and DBP 75 mm Hg, doubling for each 20-mm Hg SBP or 10-mm Hg DBP increase. Approximately 80% of stroke patients have antecedent hypertension, and 75% to 91% of individuals who develop heart failure have antecedent hypertension.
  • Treatment evidence includes about 1 mm Hg SBP decrease per kg weight loss in shorter follow-up and about 6 mm Hg SBP decrease per 10 kg weight loss longer term; bariatric surgery meta-analysis showed 61.2% mean excess weight loss, hypertension resolved in 61.7% and resolved or improved in 78.5%. RAAS inhibitors are favored in obese patients, while beta-blockers are to be avoided except for specific cardiac indications.

Methods

  • Design: joint position paper/narrative review sponsored by The Obesity Society and the American Society of Hypertension, divided into six sections plus a summary: pathophysiology, epidemiology and cardiovascular risk, metabolic syndrome, lifestyle management, pharmacologic treatment of hypertension in the obese, and medical/surgical treatment of obesity in obese hypertensive patients.
  • Data/sample: no new primary data collection; the paper synthesizes population studies, clinical trials, meta-analyses, and guidelines, including NHANES, Framingham, CARDIA, MRFIT, TOHP, TONE, Swedish Obese Subjects, and others.
  • Analysis: narrative synthesis of literature and expert recommendations; no systematic search strategy, formal inclusion criteria, or meta-analytic methods are described.

Limitations

  • The paper states that no consensus exists on the precise definition or diagnostic criteria for metabolic syndrome; that there is no consensus on the most effective long-term behavioral strategies for lifestyle modification; that evidence for lowering BP targets much below 140/90 mm Hg is limited; and that recommendations for specific antihypertensive agents in obese patients lack longitudinal outcome studies.
  • Evident from the text: as a position paper/narrative review, it does not use a systematic review process, and its recommendations rely on mixed evidence, expert opinion, and indirect evidence from non-obese or general hypertensive populations.
  • Evident from the text: several cited intervention findings are modest or uncertain, including a childhood obesity meta-analysis showing a small standardized mean difference in adiposity of −0.15 kg/m² with heterogeneity and possible small-study bias, and limited long-term data on lifestyle interventions.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1111/jch.12049

Cites

Statistics

Nothing to recompute.

Claims the paper makes

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  • Findingcitation

    In a meta-analysis of nine randomized controlled trials, patients treated with phentermine along with diet and lifestyle lost 3.6 kg more than patients treated with diet and lifestyle alone.

    “The pooled analysis showed that those treated with phentermine along with diet and lifestyle lost 3.6 kg more than patients treated with diet and lifestyle alone.”
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    In the Diabetes Prevention Program trial, mean weight loss was 0.1, 2.1, and 5.6 kg in the placebo, metformin, and lifestyle-intervention groups, respectively.

    “During this time, the mean weight loss was 0.1, 2.1, and 5.6 kg in the placebo, metformin, and lifestyle-intervention groups, respectively.”
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    Orlistat 60 mg reduces absorption of ingested fat by approximately 25% compared with roughly 30% with the 120-mg dose.

    “This dose has been shown to reduce absorption of ingested fat by approximately 25% as compared with roughly 30% with the 120-mg dose.190”
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    In a recent study of obese patients on a low-carbohydrate diet, weight loss was significantly greater in the phentermine group compared with the placebo group.

    “Weight loss was significantly greater in the phentermine group compared with the placebo group.”
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  • Findingcitation

    In one study, the mean placebo-corrected weight loss in the orlistat group was 2.8 kg while in combination with a hypocaloric diet and lifestyle modification.

    “In one, 188 the mean placebo-corrected weight loss in the orlistat group was 2.8 kg while in combination with a hypocaloric diet and lifestyle modification.”
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    Findingcitation

    Statistically significant but small placebo-corrected reductions in BP and LDL cholesterol were noted with orlistat.

    “Statistically significant but small placebo-corrected reductions in BP, and LDL cholesterol were noted.”
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    Findingcitation

    Nearly two thirds of weight lost with orlistat was maintained at the end of 2 years, and the losses remained significantly greater than with placebo.

    “Nearly two thirds of weight lost with this agent was maintained at the end of 2 years, and the losses remained significantly greater than with placebo.”
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    Findingcitation

    In that study, SBP and DBP decreased from baseline in both groups and heart rate did not differ.

    “Additionally, SBP and DBP decreased from baseline in both groups and heart rate did not differ.”
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    Findingcitation

    At 10 years, SBP in the surgery group had increased 0.5 mm Hg from baseline, compared with 4.4 mm Hg in the control group, while DBP remained 2.6 mm Hg below baseline, compared with 2.0 mm Hg below baseline in the control group.

    “At 10 years, SBP in the surgery group had increased 0.5 mm Hg from initial baseline, as compared with 4.4 mm Hg in the control group, while DBP remained 2.6 mm Hg below baseline, as compared with 2.0 mm Hg below baseline in the control group.”
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    Findingcitation

    In that meta-analysis, diabetes resolved in 76.8% of patients and resolved or improved in 86.0%, whereas hypertension resolved in 61.7% of patients and resolved or improved in 78.5%.

    “Diabetes resolved in 76.8% of patients and resolved or improved in 86.0%, whereas hypertension resolved in 61.7% of patients and resolved or improved in 78.5%.”
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    Findingcitation

    In one study, placebo-corrected weight loss at month 12 for the pramlintide 120 microgram three times daily group averaged 6.1 kg, with higher doses providing little additional benefit.

    “In one study, 215 placebo-corrected weight loss at month 12 for the pramlintide 120 lg three times daily group averaged 6.1 kg, with higher doses providing little additional benefit.”
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    Findingcitation

    In type 1 diabetic patients, pramlintide fostered modest weight loss when added to an insulin regimen and was without effect on BP.

    “In type 1 diabetic patients, pramlintide fostered modest weight loss when added to an insulin regimen and was without effect on BP. 210,211”
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    Findingcitation

    At 2 years, the surgery group demonstrated significant decreases in SBP (-4.4 mm Hg) and DBP (-5.2 mm Hg) compared with increases in SBP (+0.5 mm Hg) and DBP (+0.3 mm Hg) in the control group.

    “At 2 years, the surgery group demonstrated significant decreases in SBP ()4.4 mm Hg) and DBP ()5.2 mm Hg) as compared with increases in SBP (+0.5 mm Hg) and DBP (+0.3 mm Hg) seen in the control group.”
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    Findingcitation

    In the Diabetes Prevention Program trial, BP decreased in the lifestyle intervention group but not in the metformin group.

    “BP decreased in the lifestyle intervention group but not in the metformin group.160,199,200”
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    Findingcitation

    Recovery from hypertension was more common in the surgery group at both 2 years (21% control vs 34% surgery) and 10 years (11% control vs 19% surgery), but no change in hypertension incidence rate was noted between groups at the 2- and 10-year analysis.

    “Although recovery from hypertension was more common in the surgery group at both 2 years (21% control vs 34% surgery) and 10 years (11% control vs 19% surgery), no change in hypertension incidence rate was noted between groups at the 2-and 10-year analysis.220”
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    Findingcitation

    Multiple trials of exenatide have demonstrated statistically significant reductions in weight and BP over a prolonged period, but the changes in BP were small.

    “Multiple trials assessing the efficacy of exenatide have demonstrated statistically significant reductions in weight and BP [202][203][204][205] over a prolonged period but the changes in BP were small.206,207”
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    Findingcitation

    A small increase in pulse rate and a transient increase in BP was noted in the naltrexone/bupropion treatment groups.

    “A small increase in pulse rate and a transient increase in BP was noted in the NB treatment groups.217”
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    Findingcitation

    In the Swedish Obese Subjects Study, after 2 years, weight increased by 0.1% in the control group and decreased by 23.4% in the bariatric surgery group; after 10 years, weight increased by 1.6% in the control group and decreased by 16.1% in the bariatric surgery group.

    “After 2 years, patients' weight had increased by 0.1% in the control group and had decreased by 23.4% in the bariatric surgery group, whereas after 10 years, weight had increased by 1.6% in the control group and decreased by 16.1% in the bariatric surgery group.”
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    Findingcitation

    The pramlintide 120 microgram three times daily group demonstrated a significant placebo-corrected 4.6-mm Hg reduction in SBP and a trend toward improvement with a placebo-corrected 2.6-mm Hg decrease in DBP.

    “Furthermore, the pramlintide 120 lg three times daily group demonstrated a significant placebocorrected 4.6-mm Hg reduction in SBP and a trend toward improvement with a placebo-corrected 2.6-mm Hg decrease in DBP.”
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    Findingcitation

    GLP-1 agonists have been shown to decrease food intake and enhance satiety, suggesting a possible role in the treatment of obesity.

    “In addition to improving glycemic control, these GLP-1 agonists have been shown to decrease food intake and enhance satiety, suggesting a possible role in the treatment of obesity.201”
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    • Rests on an assumption: Incretins play an important role in glucose homeostasis by increasing insulin release from pancreatic beta-cells and suppressing the release of glucagon from pancreatic alpha-cells.
    • Rests on an assumption: GLP-1 agonists enhance glucose-dependent insulin secretion, suppress inappropriate glucagon secretion, and slow gastric emptying.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § Obesity-Related Hypertension: Pathogenesis, Cardiovascular Risk, and Treatment A Position Paper of The Obesity Society and the American Society of Hypertension

    Approximately two thirds of US adults are overweight or obese (BMI ≥25) and one third are obese (BMI ≥30).

    “The most recent National Health and Nutrition Examination Survey indicates that approximately two thirds of US adults are presently classified as overweight or obese (body mass index [BMI] 25) and one third as obese (BMI 30).1,2”
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    Premisecitation

    In NHANES, the prevalence of hypertension among obese individuals (BMI ≥30 kg/m2) is 42.5%, compared with 27.8% for overweight individuals (BMI 25.0-29.9 kg/m2) and 15.3% for those with BMI <25 kg/m2.

    “Recent data from NHANES indicate that the prevalence of hypertension among obese individuals, with a BMI 30 kg ⁄ m 2 , is 42.5% compared with 27.8% for overweight individuals (BMI 25.0-29.9kg ⁄ m 2 ) and 15.3% for those with BMI <25 kg ⁄ m 2 .52”
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    Premisecitation

    Numerous studies have demonstrated the important role of weight gain in blood pressure elevation and of weight reduction in blood pressure lowering.

    “Numerous studies have also demonstrated the important role of weight gain in BP elevation and of weight reduction in BP lowering.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Obesity is a major cause of high blood pressure, and the combination of obesity and hypertension is a pre-eminent cause of cardiovascular risk.

    “obesity is recognized as a major cause of high BP, and the combination of obesity and hypertension is recognized as a pre-eminent cause of CV risk.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    High waist-to-hip ratio is associated with significant cardiovascular risk, including hypertension, myocardial infarction, and type 2 diabetes mellitus.

    “population-based studies in Scandinavia, using waist to hip ratio as a quantifiable surrogate for the upper body phenotype, demonstrated significant CV risk (hypertension, myocardial infarction, and type 2 diabetes mellitus) in association with a high waist to hip ratio.[6][7][8]”
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    Premisecitation

    Leptin is produced in adipocytes and secreted into plasma, where its circulating concentration reflects the fat mass of the individual.

    “Leptin, the polypeptide product of the ob ⁄ ob gene, is produced in adipocytes and secreted into plasma where the circulating concentration reflects the fat mass of the individual.23”
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    Premisecitation

    Nearly 70% of American adults are overweight or obese.

    “At the same time, nearly 70% of American adults are overweight or obese.51”
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    Interpretationcitation

    Age-related changes in blood pressure may not be inevitable and may be caused more by age-related weight gain than by aging per se.

    “Hence, age-related changes in BP may not be inevitable, and may be caused more by age-related weight gain than aging per se.”
    Quote in the paperSubstantial claim

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    Premisecitation

    In a large birth cohort, children who were overweight at age 5 but had normal BMI at age 14 had similar mean systolic and diastolic blood pressure to those with normal BMI at both time points, whereas children who were overweight at both ages or normal at age 5 and overweight at age 14 had higher systolic and diastolic blood pressure at age 14 even after adjustment for potential confounders.

    “Children who were overweight at age 5 but had normal BMI at age 14 had similar mean SBP and DBP to those who had a normal BMI at both time points.Conversely, children who were overweight at both ages or who had a normal BMI at age 5 and were overweight at age 14 had higher SBP and DBP at age 14 than those who had a normal BMI at both ages, even after adjustment for potential confounders.57”
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    Premisecitation

    Although leptin deficiency causes severe obesity in animals and humans, all but a vanishingly small minority of obese humans have elevated leptin levels.

    “Although leptin deficiency causes severe obesity in animals and humans, all but a vanishingly small minority of obese humans have elevated leptin levels.23,26”
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    Premiseown data

    Epidemiological data support the link between body weight and blood pressure, and greater body weight is one of the major risk factors for high blood pressure.

    “Epidemiological data unequivocally support the link between body weight and BP.Indeed, greater body weight is one of the major risk factors for high BP.”
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    Premisecitation

    Cardiovascular and metabolic complications of obesity are more common in patients with upper body/android obesity than in those with lower body/gynoid obesity.

    “Vague noted that the CV and metabolic complications of obesity were more common in patients with the upper body obesity phenotype, which he called ''android,'' as compared with lower body obesity, which he referred to as ''gynoid.''”
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    Premisenone given

    Hypertension is a highly prevalent and highly significant risk factor for all manifestations of cardiovascular disease, including coronary heart disease, stroke, heart failure, aortic and peripheral arterial disease, and valvular heart disease.

    “hypertension is a highly prevalent and highly significant risk factor for the development of all manifestations of CVD, including coronary heart disease (CHD), stroke, heart failure (HF), aortic and peripheral arterial disease, and valvular heart disease.”
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    Premisecitation

    When infused into animals, leptin raises blood pressure, stimulates the sympathetic nervous system, and correlates with blood pressure in at least some human populations.

    “When infused into animals, leptin raises the BP, 27 stimulates the SNS, 28 and has been shown to correlate with BP, in at least some human populations.29,30”
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    Premisecitation

    Leptin is a potent appetite suppressant and stimulates the sympathetic nervous system.

    “Leptin is a potent appetite suppressant and, like insulin, stimulates the SNS.24,25”
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    Premisecitation

    In NHANES 2005-2008, the prevalence of hypertension among US adults 18 years or older was 30.9%, and more than 76 million US adults were estimated to have hypertension.

    “Data from recent US National Health and Nutrition Examination Surveys (NHANES) from 2005 to 2008 indicate that the prevalence of hypertension among adults 18 years older in the United States was 30.9%, or nearly 1 in 3 adults.In the context of the entire population, more than 76 million US adults are estimated to have hypertension.50”
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    Premisereasoning

    With the current obesity epidemic extending into its third decade, prevalence rates of hypertension, which had been falling in the 1970s and 1980s, are again rising.

    “With the current obesity epidemic extending into its third decade, prevalence rates of hypertension, which had been falling in the 1970s and 1980s, are again rising.”
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    Premisecitation

    Lowering insulin by low-energy diets in obese patients decreases blood pressure and sympathetic nervous system activity.

    “This is supported by studies demonstrating concomitant decreases in BP and SNS activity when insulin is lowered by low energy diets in obese patients.21”
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    Premisecitation

    In CARDIA, women who maintained stable BMI had nonsignificant declines in systolic blood pressure, whereas women whose BMI increased had statistically significant average increases in systolic blood pressure of 9.8 to 12.5 mm Hg.

    “For example, women who maintained stable BMI in this study had nonsignificant declines in SBP, whereas women whose BMI increased had statistically significant average increases in SBP of 9.8 mm Hg to 12.5 mm Hg.”
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    Premisecitation

    Low birth weight is associated with excessive weight gain in childhood and adolescence, along with increased risk of hypertension and stimulation of the sympathetic nervous system in adulthood.

    “low birth weight, which is associated with excessive weight gain in childhood and adolescence, along with increased risk of hypertension and stimulation of the SNS [45][46][47] in adulthood”
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    Premisecitation

    In the CARDIA study, young adults who maintained a stable BMI had no significant changes in systolic or diastolic blood pressure, whereas those who had an increase in BMI ≥2 kg/m2 had substantial increases in blood pressure.

    “In the Coronary Artery Risk Development in Young Adults (CARDIA) study, young adults (mean age 25 years at baseline) who maintained a stable BMI (within 2 kg ⁄ m 2 of baseline) at 6 examinations during 15 years had no significant changes in SBP or DBP, whereas those who had an increase in their BMI 2 kg ⁄ m 2 had substantial increases in BP. 56”
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    Premisecitation

    In CARDIA, weight gain was more important than baseline weight, since the same patterns were observed for those who were at normal weight or overweight at baseline.

    “Of note, this weight gain was more important than the baseline weight, since the same patterns were observed for those who were at normal weight or overweight at baseline.”
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    Premisecitation

    In the first of two large randomized controlled trials from Australia, 1147 10- to 12-year-olds from 30 schools found improved BP, a reduction in fatness, and improved physical fitness.

    “The first 1147 10-to 12-year-olds from 30 schools found improved BP, a reduction in fatness, and improved physical fitness.97”
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    Premisecitation

    For many cardiovascular disease endpoints, there is effect-modification by sex, with hypertensive men at higher absolute risk for cardiovascular disease events than hypertensive women, except for heart failure.

    “For many CVD endpoints, there is effect-modification by sex, with hypertensive men being at higher absolute risk for CVD events than hypertensive women.HF is a notable exception to this generalization.”
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    Premisenone given

    Hypertension confers a threefold relative risk for stroke compared with blood pressure levels <140/<90 mm Hg, and approximately 80% of individuals who experience a stroke have antecedent hypertension.

    “Hypertension confers a threefold relative risk for stroke compared with BP levels <140 ⁄ <90 mm Hg, and approximately 80% of individuals who experience a stroke have antecedent hypertension.”
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    Premisecitation

    In the ADAPT trial, in the intervention group, weight loss and reduction in waist girth were significantly greater with the intervention after 4 months and 1 year, but decrease in BP was greater only at 4 months.

    “In the intervention group, weight loss and reduction in waist girth were significantly greater with the intervention after 4 months and 1 year, but decrease in BP was greater only at 4 months.”
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    Premisecitation

    Beginning at 115 mm Hg, the risk for coronary heart disease death doubles for each increase of 20 mm Hg in systolic blood pressure; similarly, coronary heart disease death risk doubles for each increase of 10 mm Hg in diastolic blood pressure beginning at 75 mm Hg.

    “The Prospective Studies Collaboration observed that beginning at 115 mm Hg, the risk for CHD death doubles for each increase of 20 mm Hg in SBP.Similarly, CHD death risk doubles for each increase of 10 mm Hg in DBP beginning at 75 mm Hg. 58”
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    Premisecitation

    Those who are obese tend to show clustering of behaviors predisposing to higher BP including not only disturbed energy balance but less healthy diets with higher salt intake, less fruit and vegetable intake, less low-fat dairy products and increased saturated fat intake, sedentary behaviors, and in many communities high alcohol consumption.

    “Those who are obese tend to show clustering of behaviors predisposing to higher BP including not only disturbed energy balance but less healthy diets with higher salt intake, less fruit and vegetable intake, less low-fat dairy products and increased saturated fat intake, 99,105 sedentary behaviors, and in many communities high alcohol consumption.”
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    Premisecitation

    Salt restriction decreases the risk of hypertension with or without weight loss as well as reducing the incidence of CV events.

    “Salt restriction decreases the risk of hypertension with or without weight loss as well as reducing the incidence of CV events.133”
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    Premisecitation

    In TOHP phase I, seven years later, the odds ratio for hypertension among 181 participants was lower by 77% with weight loss and 35% with sodium restriction.

    “Seven years later, the odds ratio for hypertension among 181 participants was lower by 77% with weight loss and 35% with sodium restriction.”
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    Premisecitation

    Risk for coronary heart disease mortality is not limited to patients with frank hypertension; there is a linear, graded risk for coronary heart disease death that extends down even to optimal levels of blood pressure.

    “Risk for CHD mortality is not limited to patients with frank hypertension, however.There is a linear, graded risk for CHD death that extends down even to optimal levels of BP.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [58] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Elevated blood pressure is one of the major risk factors contributing to the estimated 1.4 million coronary heart disease events that occur in the United States annually.

    “Elevated BP is one of the major risk factors contributing to the estimated 1.4 million CHD events that occur in the United States annually.51”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [51] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In adults aged 55 in the Framingham Heart Study, the lifetime risk for stroke was >1 in 6, but it was twice as high among those with hypertension compared with those who had blood pressure <120/<80 mm Hg.

    “In adults aged 55 in the Framingham Heart Study, the lifetime risk for stroke was >1 in 6, but it was twice as high among those with hypertension compared with those who had BP <120 ⁄ <80 mm Hg. 65”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [65]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Hypertension represents the predominant risk factor for stroke, but the risk in people with elevated blood pressure varies over as much as a 10-fold range depending on the degree of exposure to other risk factors.

    “hypertension represents the predominant risk factor for stroke, but the risk in people with elevated BP varies over as much as a 10-fold range depending on the degree of exposure to the other risk factors.66”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [66] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Aerobic exercise can reduce weight and BP, but when exercise is the only intervention, weight losses are small, with an estimated change of 1.6 kg in moderate-intensity programs continued for 6 to 12 months.

    “Aerobic exercise can reduce weight and BP, but when exercise is the only intervention, weight losses are small, with an estimated change of 1.6 kg in moderate-intensity programs continued for 6 to 12 months.124,139,140”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [124] source

      Not checked in the free run.

    • cites [139] source

      Not checked in the free run.

    • cites [140] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the TONE study, the relative hazard ratio was 0.60 for reduced sodium alone, 0.64 for weight loss alone, and 0.47 for the combined intervention.

    “The relative hazard ratio was 0.60 for reduced sodium alone, 0.64 for weight loss alone, and 0.47 for the combined intervention.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [138]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Absolute levels of predicted hard coronary heart disease risk increase substantially with increasing risk factor burden, and risk is augmented further by increases in blood pressure levels from optimal to marked hypertension in men and similarly for women.

    “As shown in Figure 1, absolute levels of predicted hard CHD risk (including CHD death or nonfatal myocardial infarction) increase substantially with increasing risk factor burden, and risk is augmented still further by increases in BP levels from optimal to marked hypertension in men and similarly for women.63”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [63] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Given the unexplained heterogeneity and the likelihood of small study bias, the findings of the Cochrane review must be interpreted cautiously.

    “Given the unexplained heterogeneity and the likelihood of small study bias, however, these findings must be interpreted cautiously.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Mediterranean and lacto-ovovegetarian diets are also associated with benefits in relation to CV risk, weight control, and BP, but vegetarian diets are not widely acceptable.

    “Mediterranean 122 and lactoovovegetarian 123 diets are also associated with benefits in relation to CV risk, weight control, and BP, but vegetarian diets are not widely acceptable.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [122] source

      Not checked in the free run.

    • cites [123]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Hypertension rarely occurs in isolation and confers increased risk for cardiovascular disease across the spectrum of overall risk factor burden, with increasing importance in the setting of other risk factors.

    “Hypertension rarely occurs in isolation, 62 and it confers increased risk for CVD across the spectrum of overall risk factor burden, with increasing importance in the setting of other risk factors.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [62]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In a longitudinal analysis, weight gain in US adults was positively associated with small changes that included increased consumption of sugars, starches, refined grains, and processed foods as well as increased alcohol intake, time spent watching television, and decreased physical activity; weight change related inversely to consumption of fruit and vegetables, whole grains, nuts, and yogurt.

    “In a longitudinal analysis, 105 weight gain in US adults was positively associated with small changes that included increased consumption of sugars, starches, refined grains, and processed foods as well as increased alcohol intake, time spent watching television, and decreased physical activity; weight change related inversely to consumption of fruit and vegetables, whole grains, nuts, and yogurt.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [105] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    There is substantial effect-modification by age, with older hypertensive patients at similar or higher relative risk but much greater absolute risk than younger patients.

    “There is also substantial effect-modification by age, with older hypertensive patients being at similar or higher relative risk but much greater absolute risk than younger patients.61”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [61]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Excessive postnatal weight gain in early childhood dominated over effects of birth weight, especially in children of mothers who smoked in pregnancy or did not breastfeed.

    “Excessive postnatal weight gain in early childhood dominated over effects of birth weight, 94 especially in children of mothers who smoked in pregnancy or did not breastfeed.94”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [94]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In TOHP phase II, in the sodium reduction group, a decrease in BP was greater at each time point and also became attenuated with time, from 5.1/4.4 mm Hg at 6 months to 0.7/3.0 mm Hg at 3 years.

    “In the sodium reduction group, a decrease in BP was greater at each time point and also became attenuated with time, from 5.1 ⁄ 4.4 mm Hg at 6 months to 0.7 ⁄ 3.0 mm Hg at 3 years.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [136] source

      Not checked in the free run.

    • cites [137]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Calcium channel blockers are also effective in the treatment of obesity-related hypertension and have not been associated with weight gain or adverse changes in lipids.

    “Calcium channel blockers are also effective in the treatment of obesity-related hypertension and have not been associated with weight gain or adverse changes in lipids.[174][175][176]”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [174]

      Not checked in the free run.

    • cites [175]

      Not checked in the free run.

    • cites [176]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Metformin promotes mild weight loss by decreasing hepatic glucose production, decreasing intestinal absorption of glucose, and improving insulin sensitivity by increasing peripheral glucose uptake and utilization.

    “It has been shown to promote mild weight loss by decreasing hepatic glucose production, decreasing intestinal absorption of glucose, and improving insulin sensitivity by increasing peripheral glucose uptake and utilization.198”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [198]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The pressor effect of alcohol has been established in clinical trials, with an estimated increase in SBP of 1 mm per 10 g of alcohol.

    “The pressor effect of alcohol has been established in clinical trials, with an estimated increase in SBP of 1 mm per 10 g of alcohol.148”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [148]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Beta-blockers have been shown to cause insulin resistance and have been closely associated with weight gain and higher body weights, as well as decreased diet-induced thermogenesis, fat oxidation rate, and weekly habitual activity.

    “b-Blockers have been shown to cause insulin resistance and have been closely associated with weight gain and higher body weights, as well as decreased diet-induced thermogenesis, fat oxidation rate, and weekly habitual activity.[178][179][180]”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [178]

      Not checked in the free run.

    • cites [179]

      Not checked in the free run.

    • cites [180]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    A more recent meta-analysis found that resistance training of at least 4 weeks resulted in an estimated decrease of 3.9/3.9 mm Hg in normotensive or prehypertensive individuals, but a decrease of 4.1/1.5 mm Hg in hypertensive patients was not statistically significant.

    “A more recent meta-analysis 143 found that resistance training of at least 4 weeks resulted in an estimated decrease of 3.9 ⁄ 3.9 mm Hg in normotensive or prehypertensive individuals, but a decrease of 4.1 ⁄ 1.5 mm Hg in hypertensive patients was not statistically significant.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [143]

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    To reduce the incidence of CV and renal complications, target BPs for the general population should be <140/90 mm Hg and for patients with established diabetes or chronic kidney disease <130/80 mm Hg, but there is limited evidence in support of this lower threshold.

    “To reduce the incidence of CV and renal complications, target BPs for the general population should be <140 ⁄ 90 mm Hg and for patients with established diabetes or chronic kidney disease <130 ⁄ 80 mm Hg, 121 but there is limited evidence in support of this lower threshold.165”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [121]

      Not checked in the free run.

    • cites [165]

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The demonstration of functional BAT in adult humans raises the possibility that beta-3-adrenergic agonists might stimulate energy output, but none are currently available.

    “The demonstration of functional BAT in adult humans raises the possibility that b 3 -adrenergic agonists might stimulate energy output; however, none are currently available.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Smoking increases BP acutely, with an associated rise in arterial stiffness that lasts longer in hypertensive men.

    “Smoking increases BP acutely, with an associated rise in arterial stiffness that lasts longer in hypertensive men.153”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [153]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    According to National Institutes of Health guidelines, pharmacotherapy for obesity can be considered if a patient has a BMI >=30, or a BMI >=27 if weight-related comorbidities, including hypertension, type 2 diabetes, dyslipidemia, and/or obstructive sleep apnea, are present.

    “According to National Institutes of Health guidelines, pharmacotherapy for obesity can be considered if a patient has a BMI 30, or a BMI 27 if weight-related comorbidities, including hypertension, type 2 diabetes, dyslipidemia, and ⁄ or obstructive sleep apnea, are present.182”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [182]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In adults at risk for diabetes, a program of diet and physical activity reduced the risk of diabetes by 58%, with size of the decrease related to the extent of change in lifestyle.

    “In adults at risk for diabetes, a program of diet and physical activity reduced the risk of diabetes by 58%, with size of the decrease related to the extent of change in lifestyle.159”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [159] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    A systematic review of longitudinal studies of sedentary behaviors in adults found insufficient evidence for an association between sedentary behaviors and measures of adiposity or CV risk factors, including self-reported hypertension, but there was moderate evidence for an association with type 2 diabetes and strong evidence for an association with all-cause and CVD mortality.

    “A systematic review of longitudinal studies of sedentary behaviors in adults found insufficient evidence for an association between sedentary behaviors and measures of adiposity or CV risk factors, including self-reported hypertension, 147 but there was moderate evidence for an association with type 2 diabetes and strong evidence for an association with all-cause and CVD mortality.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [147] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    When beta-blockers are indicated, agents with a vasodilating component such as carvedilol and nebivolol appear to have less weight gain potential and less of an impact on carbohydrate and lipid metabolism.

    “When b-blockers are indicated, agents with a vasodilating component such as carvedilol and nebivolol appear to have less weight gain potential and less of an impact on carbohydrate and lipid metabolism.179,181”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [179]

      Not checked in the free run.

    • cites [181]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In a factorial trial of independent and combined effects of alcohol moderation and weight reduction in overweight and obese hypertensive drinkers, effects on BP were additive over a 3-month period, with the combined modalities achieving a 14/9 mm Hg BP reduction compared with controls who maintained usual weight and drinking habits.

    “In a factorial trial of independent and combined effects of alcohol moderation and weight reduction in over-weight and obese hypertensive drinkers, effects on BP were additive over a 3-month period, with the combined modalities achieving a 14 ⁄ 9 mm Hg BP reduction compared with controls who maintained usual weight and drinking habits.151”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [151]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Although thiazide diuretics are often recommended as first-line agents for the treatment of hypertension, their known dose-related side effects, which include dyslipidemia and insulin resistance, are undesirable in obese populations prone to the metabolic syndrome and type 2 diabetes.

    “Although thiazide diuretics are often recommended as first-line agents for the treatment of hypertension, 177 their known dose-related side effects, which include dyslipidemia and insulin resistance, are undesirable in obese populations prone to the metabolic syndrome and type 2 diabetes.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [177]

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Orlistat induces modest weight loss, along with improved lipid parameters, but has only minimal effects on BP.

    “Orlistat, therefore, induces modest weight loss, along with improved lipid parameters, but has only minimal effects on BP.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Roughly 30% of ingested lipids are not absorbed in the presence of orlistat 120 mg, resulting in a caloric deficit that has been shown to produce statistically significant weight loss.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Drugs that regulate appetite will likely involve the central nervous system.

    “Drugs that regulate appetite will likely involve the central nervous system.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    In the treatment of obesity, peripherally acting agents such as beta-3-agonists may be useful at increasing energy expenditure.

    “In the treatment of obesity, peripherally acting agents (b 3 -agonists, for example) may be useful at increasing energy expenditure.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: In the treatment of hypertension, agents that operate in the periphery, outside the central nervous system, provide BP control with a minimum of off-target side effects.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    As the prevalence of obesity increases, the prevalence of hypertension with its associated cardiovascular risk will increase as well.

    “As the prevalence of obesity increases, the prevalence of hypertension with its associated CV risk will increase as well.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The need to address multiple targets in the treatment of obesity will likely be required as well.

    “The need to address multiple targets in the treatment of obesity will likely be required as well.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: In the treatment of hypertension, agents that block the RAAS, the SNS and renal sodium excretion are frequently required.
    • Rests on an assumption: In the treatment of hypertension, agents that operate in the periphery, outside the central nervous system, provide BP control with a minimum of off-target side effects.

  • May combine two claims.

    Premisecitation

    Pramlintide promotes weight loss by slowing gastric emptying, increasing satiety, decreasing postprandial glucagon secretion, and centrally decreasing appetite and total caloric intake.

    “Pramlintide promotes weight loss by a variety of effects that include slowing gastric emptying, increasing satiety, decreasing postprandial glucagon secretion, and centrally decreasing appetite and total caloric intake.209”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [209]

      Not checked in the free run.

    • Rests on an assumption: Amylin is a beta-cell polypeptide co-stored with insulin and co-released with insulin in response to meals.
    • Rests on an assumption: In diabetic patients, amylin, as well as insulin secretion, is deficient.
    • Rests on an assumption: Pramlintide is a synthetic injectable congener that mimics the actions of amylin.
79 of 79

  • The authors state this as an assumption.

    Modifying surrogate markers and risk factors for cardiovascular disease toward desirable levels will translate into decreased cardiovascular morbidity and mortality.

    “Treatment should address the underlying pathophysiology and modify the surrogate markers and risk factors for CV disease (CVD) toward desirable levels in the apparently justifiable belief that this will translate into decreased CV morbidity and mortality.”

  • The paper relies on this without support.

    The abnormalities characteristic of the metabolic syndrome occur together much more commonly than predicted by chance alone.

    “Although the abnormalities characteristic of the metabolic syndrome are relatively common in the population at large, there is no doubt that these traits occur together much more commonly than predicted by chance alone.”

  • The paper relies on this without support.

    The lifestyle factors contributing to the rising epidemic of obesity are embedded in changes in society worldwide.

    “The lifestyle factors contributing to the rising epidemic of obesity, and hence obesity-related hypertension, are embedded in changes in society worldwide: increased sedentariness from the car, television, and computers; parental protectiveness in seemingly hostile urban environments; and increased consumption of calorie-rich foods in the form of soft drinks, fast foods, and sugar-enriched low-fat”

  • The paper relies on this without support.

    BAT, via SNS activation and a beta-receptor cyclase-linked mechanism, uncouples fatty acid oxidation from ATP formation generating heat rather than stored forms of energy.

    “BAT, via SNS activation and a b-receptor cyclase-linked mechanism, uncouples fatty acid oxidation from ATP formation generating heat rather than stored forms of energy.”

  • The paper relies on this without support.

    Roughly 30% of ingested lipids are not absorbed in the presence of orlistat 120 mg, resulting in a caloric deficit that has been shown to produce statistically significant weight loss.

    “Roughly 30% of ingested lipids are not absorbed in the presence of orlistat 120 mg, resulting in a caloric deficit that has been shown to produce statistically significant weight loss.”

  • The paper relies on this without support.

    Many of the medications available to treat type 2 diabetes are associated with weight gain and increased fat deposition.

    “Many of the medications available to treat type 2 diabetes are associated with weight gain and increased fat deposition.”

  • The paper relies on this without support.

    Incretins play an important role in glucose homeostasis by increasing insulin release from pancreatic beta-cells and suppressing the release of glucagon from pancreatic alpha-cells.

    “Incretins play an important role in glucose homeostasis by increasing insulin release from pancreatic b-cells and suppressing the release of glucagon from pancreatic a-cells.”

  • The paper relies on this without support.

    GLP-1 agonists enhance glucose-dependent insulin secretion, suppress inappropriate glucagon secretion, and slow gastric emptying.

    “GLP-1 agonists enhance glucose-dependent insulin secretion, suppress inappropriate glucagon secretion (leading to decreased hepatic glucose output and decreased insulin demand), and slow gastric emptying.”

  • The paper relies on this without support.

    Amylin is a beta-cell polypeptide co-stored with insulin and co-released with insulin in response to meals.

    “Amylin is a b-cell polypeptide co-stored with insulin and co-released with insulin in response to meals.”

  • The paper relies on this without support.

    In diabetic patients, amylin, as well as insulin secretion, is deficient.

    “In diabetic patients, amylin, as well as insulin secretion, is deficient.”

  • The paper relies on this without support.

    Pramlintide is a synthetic injectable congener that mimics the actions of amylin.

    “Pramlintide is a synthetic injectable congener that mimics the actions of amylin.”

  • The paper relies on this without support.

    In the treatment of hypertension, agents that block the RAAS, the SNS and renal sodium excretion are frequently required.

    “In the treatment of hypertension, agents that block the RAAS, the SNS and renal sodium excretion are frequently required.”

  • The paper relies on this without support.

    In the treatment of hypertension, agents that operate in the periphery, outside the central nervous system, provide BP control with a minimum of off-target side effects.

    “In the treatment of hypertension, agents that operate in the periphery, outside the central nervous system, provide BP control with a minimum of off-target side effects.”
13 of 13

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Long-term follow-up is attributed to the wrong trial

    Minor

    The text calls the cited 10- to 15-year follow-up a TONE study, but reference 133 identifies it as a follow-up of the Trials of Hypertension Prevention (TOHP).

1 of 1

The citation lists haven’t been fetched yet

References 231 · Cited by 528

Research works printed but not linked: 7

  1. Pickering G, 1968, High Blood Pressure
  2. Landsberg L, 2004, The metabolic syndrome: diabetes, obesity and hypertension, Handbook of Hypertension. Hypertension in the Twentieth Century: Concepts and Achievements, 245
  3. Joint National Committee on Prevention E, and Treatment of High Blood Pressure, 2004, The Seventh Report of the Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure
  4. Genentech USA, Inc, 2010, Xenical (Orlistat) Package Insert
  5. Bristol‐Myers Squibb Company, 2009, Glucophage (metformin) Package Insert
  6. Amylin Pharmaceuticals and Eli Lilly & Company, 2010, Byetta Package Insert
  7. Amylin Pharmacueticals, 2008, Symlin (pramlintide) Package Insert

Authors
Landsberg, L., Aronne, L. J., Beilin, L. J., Burke, V., Igel, L. I., Lloyd‐Jones, D., & Sowers, J.
Affiliations
  • Northwestern University (US)
  • Cornell University (US)
  • The University of Western Australia (AU)
  • University of Missouri (US)
Corresponding author
Landsberg, Lewis
ORCID
Venue
The Journal of Clinical Hypertension
Publisher
Wiley
Published
2012-12-18
Volume
15
Issue
1
Pages
14-33
ISSN
  • 1524-6175 (ISSN-L)
  • 1751-7176
DOI
10.1111/jch.12049
PMC
PMC8108268
OpenAlex
W2102758116
Cited by
528
References
231
Citations by year
2026: 22 · 2025: 38 · 2024: 53 · 2023: 38 · 2022: 41 · 2021: 41 · 2020: 51 · 2019: 49 · 2018: 38 · 2017: 30 · 2016: 33 · 2015: 37 · 2014: 38 · 2013: 18
FWCI
4.90
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Journal of Clinical Hypertension (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • UWA Profiles and Research Repository (UWA) (submittedVersion)
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
Keywords
obesity, hypertension, pathophysiology, cardiovascular risk, metabolic syndrome, lifestyle management, antihypertensive pharmacotherapy, bariatric surgery, obesity epidemiology, hypertension prevention
MeSH terms
Antihypertensive Agents, Cardiovascular Diseases, Humans, Hypertension, Life Style, Obesity, Risk, United States, Evidence-Based Medicine

About these checks

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Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

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