ORIGINAL INVESTIGATION

Weight Loss in Overweight Adults

and the Long-term Risk of Hypertension
The Framingham Study
Lynn L. Moore, DSc, MPH; Agostino J. Visioni, MD, MPH; M. Mustafa Qureshi, MBBS, MPH;
M. Loring Bradlee, MS; R. Curtis Ellison, MD; Ralph D’Agostino, PhD

Background: Few studies address long-term effects of
weight loss on risk of incident hypertension among over-
weight adults.
Methods: We evaluated weight loss among 623 over-
weight (body mass index [calculated as weight in kilo-
grams divided by the square of height in meters] ⱖ25)
middle-aged (aged 30-49 years) and 605 overweight older
(aged 50-65 years) adults in Framingham, Mass. Sub-
jects were classified first according to amount of weight
lost over 4 years: (1) weight changed by less than 1.8 kg
(stable weight), (2) lost 1.8 to less than 3.6 kg, (3) lost
3.6 to less than 6.8 kg, and (4) lost 6.8 kg or more. We
also classified weight loss according to whether it was
sustained during the next 4 years.
Results: After adjusting for age, sex, education, base-
line body mass index, height, activity, smoking, and al-
cohol intake, weight loss of 6.8 kg or more led to a 21%
to 29% reduction in long-term hypertension risk. After
adjusting for cancer or cardiovascular disease occurring
during follow-up, weight loss of 6.8 kg or more led to a
28% reduction in risk (relative risk [95% confidence in-
terval], 0.72 [0.49-1.05]) for middle-aged adults and a
37% reduction (0.63 [0.42-0.95]) for older adults. Sus-
tained weight loss led to a 22% reduction in hyperten-
sion risk (0.78 [0.60-1.03]) among middle-aged and a
26% reduction (0.74 [0.56-0.97]) in older adults. This
risk reduction was strengthened by adjustment for preva-
lent cancer or cardiovascular disease during follow-up.
Conclusion: A modest weight loss, particularly when sus-
tained, substantially lowers the long-term risk of hyper-
tension in overweight adults.
Arch Intern Med. 2005;165:1298-1303

Author Affiliations: Section of
Preventive Medicine and
Epidemiology, Boston
University School of Medicine,
Boston, Mass (Drs Moore,
Qureshi, and Ellison and
Ms Bradlee); Department of
Neurosurgery, University of
Vermont, Burlington
(Dr Visioni); and Department of
Mathematics, Boston University
(Dr D’Agostino).
Financial Disclosure: None.
A
N ESTIMATED 50 MILLION
adults in the United States
have high blood pres-
sure.1 The strongest
known risk factor for this
disease is excess body weight,2-4 and its ad-
verse effects have been shown to start in
childhood.5,6 The treatment and primary
prevention of hypertension have re-
ceived a great deal of attention in recent
years.1,7-9 Most trials of hypertension treat-
ment have included a weight-loss compo-
nent, and these studies have for the most
part shown that weight loss, whether alone
or in combination with antihypertensive
medication use, has a beneficial effect on
blood pressure control.10-15 A few studies
examined the effects of weight loss among
those with borderline high blood pres-
sure or those who were otherwise prone
to hypertension.16-18 In all of these stud-
ies, weight loss reduced both systolic and
diastolic blood pressure, although in 2 of
the 3 studies examined, the effects dimin-
ished over the 3- to 4-year follow-up.17,18
One study16 demonstrated a 50% reduc-
tion in incident hypertension over 5 years
associated with a lifestyle intervention that
included exercise, weight loss, and other
dietary changes. A prospective epidemio-
logic study19 examined self-reported weight
loss from age 18 years to middle adult-
hood and found an overall reduction in the
risk of subsequent hypertension. In that
study, the authors were unable to com-
pare sustained and nonsustained weight
loss and did not specifically examine the
potential benefits of weight loss among
overweight individuals.
Obesity is notoriously difficult to treat;
90% of those who lose weight have been re-
ported to regain it.20 The weight-loss goals
of many overweight adults may be ex-
treme, making it even more difficult to
achieve and maintain weight loss over time.
Data on the long-term health implications
of modest weight loss are sparse, and data
evaluating the separate effects of sustained
and nonsustained weight loss are needed.
Earlier analyses from the Framing-
ham Study showed that change in weight
was associated with a linear change in

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blood pressure2,21 and that sustained weight loss was as-
sociated with a 30% reduction in the risk of diabetes melli-
tus in overweight adults.22 The goal of the current study
was to estimate the effects of both the amount of weight
lost and the persistence of the weight loss on the risk of
incident hypertension among already-overweight adults.
METHODS
The surviving members of the original 5209 subjects in the
Framingham cohort have been examined every 2 years since 1948.
At each clinical examination, subjects completed a structured in-
terview that included a detailed medical history and risk-
behavior assessment, a physical examination, and laboratory and
other measurements. All subjects provided yearly written in-
formed consent to participate, as mandated by the institutional
review board of Boston Medical Center, Boston, Mass.
Blood pressure was measured by an examining physician
using a standard mercury sphygmomanometer and an appro-
priate-sized cuff, after the subject had had a brief period of rest
in the seated position. Two measurements were taken on the
left arm, 2 minutes apart. Systolic blood pressure was defined
as the first appearance of sound (Korotkoff, phase 1), and dia-
stolic blood pressure as the disappearance of sound (Korot-
koff, phase 5). The mean of the 2 physician measurements was
taken to reflect the systolic and diastolic blood pressures at each
examination.
The outcome of interest for all analyses was incident hy-
pertension, using criteria modified slightly from the seventh
report of the Joint National Committee on Prevention, Detec-
tion, Evaluation, and Treatment of High Blood Pressure ( JNC
7).23 All subjects with a mean systolic blood pressure of 140
mm Hg or higher and/or a mean diastolic blood pressure of 90
mm Hg or higher on 2 separate examination visits were con-
sidered to be hypertensive. The JNC 7 criteria require that the
subject have elevated blood pressure readings on 2 separate vis-
its approximately 6 weeks apart. The Framingham Study ex-
aminations, however, are at 2-year intervals. We were con-
cerned that the use of measurements from a single examination
visit to define subjects as being hypertensive using the lower
JNC 7 standards would lead to unacceptably high numbers of
false-positive cases. Therefore, we required subjects to meet the
diagnostic criteria at 2 consecutive Framingham Study exami-
nations. However, subjects taking antihypertensive medica-
tion (for the purpose of blood pressure lowering) were con-
sidered to have hypertension at the examination at which such
medication use was first reported. In addition, those having frank
hypertension based on a mean systolic blood pressure of 160
mm Hg and/or a mean diastolic blood pressure of 95 mm Hg
or higher from the 2 separate physician measurements at a single
examination visit were also considered to be hypertensive.
The following potential confounding variables were exam-
ined in these analyses: age (in years), sex, height (in meters),
baseline body mass index (BMI) (calculated as weight in kilo-
grams divided by the square of height in meters), education level
(dichotomized as ⬎high school vs ⱕhigh school), alcohol in-
take (mean number of drinks per day during the weight-
change period), cigarette smoking (mean number of ciga-
rettes per day during the weight-change period), and physical
activity (mean activity index score during the weight-change
period). In a final model, we also adjusted for any occurrence
of cancer or cardiovascular disease during the follow-up pe-
riod to determine whether such comorbid conditions associ-
ated with weight loss might confound the results.
Height and weight were measured without shoes at each visit,
with subjects wearing an examination gown; a standard bal-
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Exposure Period Follow-up Period
Weight Loss Period
(Monitor for Incident Hypertension)
x x x x x | |
0 2 4 6 8 10 48
Years
Figure 1. Analysis of effect of amount of weight lost. The x’s indicate that a
weight measurement was recorded.
ance beam scale was used. To reduce the error associated with
measurement of height, we calculated the mean of all avail-
able adult height measurements through age 60 years; mean
height was combined with examination-specific weights to es-
timate BMI at each visit. Physical activity and alcohol intake
were assessed at periodic examinations. Subjects reported the
number of hours spent each day sleeping and in sedentary, light,
moderate, and vigorous physical activity. An index of moder-
ate plus vigorous physical activity was created by summing the
number of self-reported hours per day spent participating in
each level of activity multiplied by a numeric weight derived
from the estimated oxygen consumption required (in liters per
minute) for that activity level.24 The self-reported daily or weekly
consumption of beer, wine, and spirits was used to estimate
the average number of drinks per day. Cigarette smoking (av-
erage number of cigarettes per day and information on start-
ing and stopping) was assessed at each examination. For those
variables not assessed at every examination, values at the in-
termediate examinations were imputed by averaging reported
values from adjacent examinations.
Of the 3630 men and women who were followed up in the
Framingham Study at some time during their middle-adult years
(aged 30-49 years), 2188 were overweight (BMI ⱖ25) at some
time during that age interval. We excluded 279 subjects who had
incomplete weight-change data and 55 individuals who had miss-
ing covariate information. Of the remaining 1854 subjects, 21 died
before the start of follow-up, 850 were excluded owing to preva-
lent hypertension, and 2 were lost to follow-up. To reduce the
possibility of confounding by a preexisting disease, we excluded
an additional 10 subjects with prevalent diabetes, 30 with preva-
lent cardiovascular disease, and 17 with prevalent cancer. Of the
remaining 924 overweight disease-free subjects, 623 had either
stable weight or lost weight during the next 4 years and were in-
cluded in our analyses (Figure 1).
In a secondary analysis, we classified those subjects who lost
weight over 4 years according to whether they kept the weight
off during the next 4 years. In this manner, we classified each
of the weight losers from the first analysis as having sustained
or nonsustained weight loss. Finally, we excluded subjects from
the referent category (stable weight) if their weight did not re-
main stable during the weight maintenance period (Figure 2).
This yielded a final sample of 417 subjects for the analysis of
the effects of sustained and nonsustained weight loss.
We carried out the same analyses for overweight older adults
(aged 50-65 years). Applying the same inclusion/exclusion cri-
teria yielded a sample of 605 overweight subjects for the analy-
sis of the amount of weight lost and 424 subjects for the analy-
sis of sustained and nonsustained weight loss.
We selected subjects for the 2 age groups of interest (aged
30-49 years and 50-65 years) by examining each subject’s BMI
measures at sequential examination visits. On the first occa-
sion at which the subject reached a BMI of 25 or higher, he or
she was selected for the age cohort and that examination served
as the baseline examination. Thus, the baseline examination
visit varies among subjects.
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Exposure Period Follow-up Period
Weight
Weight Loss Maintenance
Period Period
(Monitor for Incident Hypertension)
x x x x x |
0 2 4 6 8 10
Years
Figure 2. Analysis of effect of maintenance of weight loss. The x’s indicate
that a weight measurement was recorded.
Figure 1 shows the timing of the exposure and follow-up
periods for the analysis of the amount of weight lost. We used
3 weight measurements from a 4-year period to calculate subject-
specific weight slopes during that interval, using a simple lin-
ear regression model with sequential measures of weight re-
gressed on age. The estimated weight loss from the linear
regression model was used to assign subjects to 1 of the 4 weight
loss categories (stable weight, lost 1.8 to ⬍3.6 kg, lost 3.6 to
⬍6.8 kg, lost ⱖ6.8 kg). Subjects who gained 1.8 kg or more
were excluded from this analysis. We excluded the first 4 years
of person-time after the end of the weight-change period to re-
move the possibility that serious preexisting illnesses might have
been responsible for the weight loss. Thus, follow-up for inci-
dent hypertension began 8 years after the baseline weight mea-
surement.
Hypertension incidence was calculated as the number of in-
cident cases of high blood pressure divided by the total num-
ber of person-years of follow-up. Total follow-up time for each
subject continued until the occurrence of 1 of the following
censoring events: incident hypertension diagnosis, death, loss
to follow-up, or examination 24 (the end of our follow-up pe-
riod). Hypertension incidence was calculated separately for those
whose weight was stable and for each category of weight loss.
We used Cox proportional hazards analyses to estimate the ad-
justed relative risk (RR) and 95% confidence intervals (CIs) as-
sociated with the amount of weight lost.25
For those subjects who lost 1.8 kg or more over 4 years,
we then examined weight change during the next 4 years (the
weight maintenance period) to allow for the assessment of the
effects of sustained and nonsustained weight loss (Figure 2).
Those who kept the weight off or who lost more weight dur-
ing the weight maintenance period were considered to have
had sustained weight loss. Those who regained the weight (ie,
regained ⱖ1.8 kg) were considered to have had nonsustained
weight loss. For this secondary analysis, subjects whose
weight remained within 1.8 kg of the baseline value through-
out the entire 8-year exposure period were considered to have
stable weight (referent category). Follow-up for hypertension
occurrence began at the end of the weight maintenance
period.
RESULTS
Table 1 provides baseline characteristics of the 623 over-
weight middle-aged adults and 605 overweight older
adults who either lost weight or had stable weight over
4 years. In both age groups, those who lost the most weight
were heaviest at baseline and more frequently female.
In Table 2, we examine the effects of the amount of
weight lost over 4 years. In both age groups, the crude
rates of hypertension were highest among those over-
weight men and women who did not lose weight de-
spite the fact that their BMI values were lowest at base-
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line. As expected, after 4 years of follow-up, the final BMI
for those with stable weight was unchanged from the base-
line BMI. Those who had lost 6.8 kg or more, however,
reduced their mean BMI by more than 3 units, giving them
a final BMI that was about 2 units lower than the final
| BMI of those who had stable weight. As would also be
48 expected, older men and women had higher rates of hy-
pertension than did middle-aged subjects regardless of
weight-change category.
In Table 2, we present 2 adjusted models. In the first,
we adjusted for age, sex, height, baseline BMI, educa-
tion level, alcohol intake, cigarette smoking, and physi-
cal activity. Here we see that middle-aged overweight
adults who lost 6.8 kg or more reduced their long-term
risk of hypertension by 21%, while older adults reduced
their risk by 29%. In the final model, after accounting
for the occurrence of cancer or cardiovascular disease dur-
ing the follow-up period, the results were strengthened.
We see that there was a trend toward a reduction in the
long-term risk of hypertension even among those who
lost more modest amounts of weight.
In Table 3, we examined the effects of sustained and
nonsustained weight loss. Sustained weight loss in middle-
aged overweight subjects resulted in 7 fewer cases of hy-
pertension per 1000 person-years than did maintaining
a stable weight (45.1 − 38.1 cases per 1000 person-
years). Sustained weight loss in older subjects resulted
in 13.3 fewer cases per 1000 person-years. In our first
adjusted model, we found that middle-aged men and
women who had a sustained weight loss of 1.8 kg or more
had a 22% reduction in the long-term risk of hyperten-
sion (RR, 0.78; 95% CI, 0.60-1.03), whereas older sub-
jects had a 26% reduction in risk (RR, 0.74; 95% CI, 0.56-
0.97). Accounting for the occurrence of comorbidities
during the follow-up period strengthened the results for
older adults, where sustained weight loss was associ-
ated with a 36% reduction in the long-term risk of hy-
pertension.
COMMENT
In this study, we examined the effect of weight loss among
overweight middle-aged and older adults on the long-
term risk of hypertension. The results of this study sug-
gest that a weight loss of 6.8 kg or more can reduce the
long-term risk of hypertension by 21% to 29%. Weight
loss of even smaller amounts is effective, particularly if
the weight loss is sustained. The results of these analy-
ses also suggest that there may be some benefit to weight
loss even when it is not sustained; there is no evidence
that regaining weight has an adverse effect on hyperten-
sion risk.
This study adds important information to the exist-
ing literature and suggests that there may be significant
long-term blood pressure benefits of modest weight loss
in middle-aged and older men and women. Although ear-
lier studies have demonstrated that weight loss reduces
blood pressure in those with prevalent hypertension as
well as those at high risk for developing hyperten-
sion,10-18 there are few data on weight loss and the long-
term risk of primary hypertension among normotensive
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 Table 1. Characteristics of Overweight Middle-Aged and Older Subjects*

Weight Change

Characteristic Stable Weight Lost 1.8 to ⬍3.6 kg Lost 3.6 to ⬍6.8 kg Lost ⱖ6.8 kg
Subjects Aged 30-49 y
No. of subjects 356 105 112 50
Baseline BMI, mean 27.0 27.7 27.7 28.8
Age, mean, y 39.9 40.7 39.6 39.0
Baseline blood pressure, mean, mm Hg
Systolic 124.0 123.0 124.9 123.0
Diastolic 79.8 79.9 80.7 80.3
Sex
Male 190 (53.4) 41 (39.0) 49 (43.8) 8 (16.0)
Female 166 (46.6) 64 (61.0) 63 (56.2) 42 (84.0)
Education, ⬎high school 113 (31.7) 29 (27.6) 24 (21.4) 11 (22.0)
Smoking, current† 201 (56.5) 67 (63.8) 68 (60.7) 29 (58.0)
Alcohol intake, nondrinker‡ 61 (17.1) 16 (15.2) 19 (17.0) 9 (18.0)
Physical activity, sedentary§ 89 (25.0) 25 (23.8) 22 (19.6) 12 (24.0)
Subjects Aged 50-65 y
No. of subjects 345 118 93 49
Baseline BMI, mean 27.2 27.6 28.0 29.1
Age, mean, y 52.2 52.7 52.3 52.3
Baseline blood pressure, mean, mm Hg
Systolic 123.0 124.2 124.0 126.8
Diastolic 79.2 78.9 79.4 80.9
Sex
Male 180 (52.2) 59 (50.0) 36 (38.7) 15 (30.6)
Female 165 (47.8) 59 (50.0) 57 (61.3) 34 (69.4)
Education, ⬎high school 102 (29.6) 33 (28.0) 25 (26.9) 10 (20.4)
Smoking, current† 158 (45.8) 57 (48.3) 38 (40.9) 19 (38.8)
Alcohol intake, nondrinker‡ 61 (17.7) 19 (16.1) 20 (21.5) 9 (18.4)
Physical activity, sedentary§ 68 (19.7) 33 (28.0) 17 (18.3) 17 (34.7)

Abbreviation: BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters).
*Subjects had a BMI of 25 or higher. Data are presented as number (percentage) of subjects unless otherwise indicated.
†Smokers were those who smoked any time during the 4-year exposure period.
‡Nondrinkers were abstainers throughout the exposure period.
§Sedentary refers to those with no daily moderate or vigorous activity at any examination during the exposure period.

Table 2. Effect of the Amount of Weight Lost on Hypertension Risk in Overweight Subjects*

No. of HTN I/1000 Baseline Final Crude RR Adjusted RR 㥋 Adjusted RR¶

Weight Change Subjects† Person-years‡ Cases Person-years BMI BMI§ (95% CI) (95% CI) (95% CI)
Subjects Aged 30-49 y
Stable 356 6277 265 42.2 27.0 27.0 1.00 1.00 1.00
Lost 1.8 to ⬍3.6 kg 105 1900 79 41.6 27.7 26.7 0.98 (0.76-1.26) 0.92 (0.71-1.18) 0.88 (0.68-1.13)
Lost 3.6 to ⬍6.8 kg 112 1974 77 39.0 27.7 25.9 0.94 (0.73-1.21) 0.91 (0.70-1.17) 0.88 (0.67-1.14)
Lost ⱖ6.8 kg 50 883 32 36.2 28.8 25.2 0.89 (0.61-1.28) 0.79 (0.54-1.15) 0.72 (0.49-1.05)
Subjects Aged 50-65 y
Stable 345 4314 239 55.4 27.2 27.1 1.00 1.00 1.00
Lost 1.8 to ⬍3.6 kg 118 1560 79 50.6 27.6 26.7 0.91 (0.70-1.17) 0.89 (0.68-1.15) 0.80 (0.61-1.04)
Lost 3.6 to ⬍6.8 kg 93 1200 62 51.7 28.0 26.2 0.93 (0.71-1.24) 0.89 (0.67-1.18) 0.81 (0.61-1.08)
Lost ⱖ6.8 kg 49 639 28 43.8 29.1 25.3 0.79 (0.54-1.17) 0.71 (0.47-1.07) 0.63 (0.42-0.95)

Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters); CI, confidence interval; HTN, incident
hypertension; I, HTN incidence; RR, relative risk.
*Subjects had a BMI of 25 or higher.
†Excludes those with prevalent hypertension, diabetes, cancer, or cardiovascular disease until 4 years after the exposure period.
‡Follow-up starts 4 years after the end of the initial 4-year exposure period.
§Final BMI refers to mean final BMI at the end of the exposure period.
㛳Adjusted for sex, baseline BMI, height, baseline age, education level, alcohol intake, cigarette smoking, and physical activity.
¶Adjusted for sex, baseline BMI, height, baseline age, education level, alcohol intake, cigarette smoking, physical activity, and occurrence of cancer or
cardiovascular disease during the follow-up period.

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 Table 3. Separate Effects of Sustained and Nonsustained Weight Loss in Overweight Men and Women

No. of HTN I per 1000 Baseline Final Crude RR Adjusted RR§ Adjusted RR 㥋
Weight Change Subjects* Person-years† Cases Person-years BMI BMI‡ (95% CI) (95% CI) (95% CI)
Subjects Aged 30-49 y
Stable weight 150 2619 118 45.1 26.8 26.9 1.00 1.00 1.00
Nonsustained loss 114 1950 81 41.5 28.2 28.1 0.93 (0.70-1.23) 0.87 (0.65-1.18) 0.88 (0.65-1.19)
Sustained loss 153 2807 107 38.1 27.8 25.6 0.81 (0.63-1.06) 0.78 (0.60-1.03) 0.77 (0.58-1.01)
Subjects Aged 50-65 y
Stable weight 164 1960 121 61.7 27.0 26.9 1.00 1.00 1.00
Nonsustained loss 102 1353 70 51.7 28.2 27.9 0.84 (0.62-1.13) 0.79 (0.58-1.07) 0.78 (0.58-1.07)
Sustained loss 158 2046 99 48.4 28.0 25.8 0.78 (0.59-1.01) 0.74 (0.56-0.97) 0.64 (0.48-0.85)

Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters); CI, confidence interval; HTN, incident
hypertension; I, HTN incidence; RR, relative risk.
*Excludes those with prevalent hypertension, diabetes, cancer, or cardiovascular disease until the start of follow-up.
†Follow-up starts at the end of the 8-year exposure period.
‡Final BMI refers to mean final BMI at the end of the exposure period.
§Adjusted for sex, baseline BMI, height, baseline age, education level, alcohol intake, cigarette smoking, and physical activity.
㛳Adjusted for sex, baseline BMI, height, baseline age, education level, alcohol intake, cigarette smoking, physical activity, and occurrence of cancer or
cardiovascular disease during the follow-up period.

adults.19 These findings may provide useful data for cli-
nicians contemplating weight-loss recommendations for
their overweight patients.
An important strength of the Framingham Study data
set is the availability of repeated measures of height and
weight over many years, allowing us to classify subjects
more accurately with respect to their BMI, as well as their
change in weight over time. Second, the routine moni-
toring and replicate standardized measurement of blood
pressure provide for more accurate detection of inci-
dent hypertension. Both factors enhanced our ability to
obtain a more accurate and precise estimate of the effect
of weight loss on long-term hypertension risk. Finally,
the repeated measures of weight enabled us to separate
the effect of weight loss that was sustained from that which
was not sustained.
Unfortunately, this observational study does not al-
low us to separate voluntary from involuntary weight loss.
Because we were concerned that a large weight loss or
persistent weight loss might be involuntary and signal
the presence of undetected preclinical illnesses, we cre-
ated a final multivariable model in which we adjusted for
serious comorbidities occurring during the follow-up pe-
riod. In this way, we hoped to reduce some of the con-
founding associated with involuntary weight loss. The
comorbid condition that resulted in the greatest change
in the effect estimates was cancer and, in fact, a final model
including cancer alone was very similar to that includ-
ing both cancer and cardiovascular disease.
There are a number of mechanisms by which weight
loss may affect the risk of hypertension. Although it is
not clear how obesity may cause high blood pressure, there
are a number of important physiological changes that ac-
company increased body weight. Obesity is associated with
higher levels of insulin resistance, as well as hyperinsu-
linemia, rises in cardiac output, increases in triglyceride
and cholesterol levels, and increases in sympathetic ner-
vous system activity.26,27 Most of these changes have also
been associated with increases in blood pressure. In re-
cent years, there has been a great deal of focus on the roles
of hyperinsulemia and insulin resistance in the develop-
ment of hypertension.27-30 These factors may increase
blood pressure in a number of ways: via an increase in
circulating epinephrine or norepinephrine, increased vas-
cular sensitivity to vasoconstrictor or vasodilator sub-
stances, enhanced sodium retention by the distal renal
tubules, and other mechanisms associated with intracel-
lular retention of free calcium or sodium (in turn, stimu-
lating vascular smooth muscle contraction).
In addition, weight loss and concurrent changes in diet
and physical activity may have direct and indirect ef-
fects on blood pressure. For example, dietary changes di-
rected at weight loss may lead to an overall reduction in
sodium intake, while exercise, even in the absence of
weight loss, decreases insulin resistance in obese indi-
viduals. Together, these factors may help explain some
of the long-term reduction in hypertension risk associ-
ated with weight loss in this study.
The results of our study show that those who lost the
most weight had the lowest BMI values at the end of the
weight-change period, and the mean BMI of individuals
who sustained their weight loss was more than 2 units
lower than their mean baseline BMI. Thus, it is plau-
sible that the beneficial effect of weight loss simply de-
rives from that lower BMI at the end of follow-up. Sub-
jects with a nonsustained weight loss had a final BMI (after
8 years) that was similar to their baseline BMI. Al-
though not statistically significant, there was a trend to-
ward a lower risk of hypertension in the long term for
those whose weight loss was not sustained. We postu-
late that reducing the BMI, even for a few years, may have
beneficial physiological effects.
Hypertension is a remarkably common condition
among overweight individuals and frequently leads to car-
diovascular sequelae, including stroke and myocardial
infarction. Prevention or even delay in the onset of hy-
pertension may reduce the occurrence of these devastat-
ing diseases. The results of this study suggest that at least
15% of the cases of hypertension in overweight middle-
aged adults and 22% of the cases occurring in over-

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weight older adults could be prevented by a modest
amount of sustained weight loss.
Accepted for Publication: January 5, 2005.
Correspondence: Lynn L. Moore, DSc, MPH, Section of
Preventive Medicine and Epidemiology, Boston Univer-
sity School of Medicine, 715 Albany St, Boston, MA 02118
(llmoore@bu.edu).
Funding/Support: This work was supported by Na-
tional Heart, Lung, and Blood Institute’s Framingham
Heart Study (Contract No. N01-HC-25195).
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