Modifiable health behaviors such as dietary interventions and recognizing hypertension behavioral symptoms could help reduce risks of hypertension for adults with obesity.  

If current trends continue, there could be a 16.4 percent increase in adults with obesity by 2030.¹ For adults with obesity, cardiovascular disease is the number one cause of morbidity and mortality among adults in the U.S.² Suboptimal health behaviors, such as poor diet and a sedentary lifestyle, are associated with an increased risk for compromised cardiovascular health. Hypertension is a major is a major cardiovascular risk factor, and statistics show that 75 percent of those with hypertension are adults with obesity.³ The negative effects of hypertension strain the health care system and compounds the financial burden for adults with obesity; thus, strategies for mitigating the negative consequences of obesity and hypertension are key.

The American Heart Association (AHA) recognizes key health factors such as body weight, dietary interventions, physical activity, and cholesterol — part of what the organization defines as Life’s Essential 8 (LE8) — as contributors to heart health and as metrics that need to be monitored in adults with obesity.⁴ Research has shown that when patients follow LE8 recommendations, reductions in risk to subclinical and clinical cardiovascular disease were observed.⁵ Modifiable health behaviors such as dietary interventions and recognizing hypertension behavioral symptoms and hypertension behavior could mitigate costs and health risks for adults with obesity.

Dietary Interventions and Modifiable Health Behaviors

Modifiable behaviors such as dietary interventions can reduce the negative health effects of hypertension. Clinically significant weight loss (CSWL) — losing greater than or equal to five percent of one’s weight — has been linked with clinical improvements in key health parameters such as hypertension.⁶ Heart-healthy diets have been recommended in conjunction with an overall healthy lifestyle for controlling hypertension. Guidelines for the Dietary Approaches to Stop Hypertension (DASH) diet and guidelines from the American Hearth Assocication⁷ suggest including fruits, vegetables, legumes, seeds, and nuts as part of a healthy eating plan. Recommendations also include reducing processed food intake and adding lean proteins (e.g., skinless fish and poultry), non-tropical vegetable oils, and low-fat dairy.

In a meta-analysis of 24 randomized control trials,⁸ a healthy diet, as noted above, resulted in a reduction of SBP and DBP (-7.6 mm HG and -4.2 mm HG, respectively). When exercise was included, reductions in blood pressure were significantly larger (-16.1 / 9.9 mm HG) compared to diet alone (-11.2/7.5 mm HG).⁸ The effect of including fruits, vegetables, etc., was further strengthened when dietary intake of sodium was reduced. For example, when sodium intake was limited to 1150 mg/d, improvements from SBP baseline were observed as follows:  130, .8 mm HG; 130 to 139, 3.3 mm HG; 140 to 149, 4.9 mm / HG; and ≥ 150, 10.9 mm HG.

Hypertension Behavioral Symptoms

Hypertension behavioral symptoms have been observed in hypertensive patients.⁹ In addition to attending to clinical metrics of hypertension, it is important for clinicians to also attend to the emotional well-being of patients who are at risk for hypertension. Research has shown that hypertensive patients exhibit “hypertension behavioral symptoms,” or symptoms that align with depression, anxiety, and stress. While a poor diet and a sedentary lifestyle can lead to an increased risk of developing hypertension, so too can psychological distress. In a recent meta-analysis⁹ that included 5,696 participants, a higher incidence of hypertension was observed in patients with psychological distress compared to those who were not experiencing psychological distress. However, the researchers caution that more research is needed in this area to fully understand this relationship.

In another study¹⁰ (n=400) investigating the relationship between hypertension and psychological distress, researchers administered the Depression, Anxiety and Stress Scale (DASS-21), a self-report inventory designed to assess psychological distress. Results show that hypertensive patients experienced depression (four percent), anxiety (56 percent), and stress (20 percent). It is important for clinicians who are treating hypertensive patients to consider a holistic approach to patient care, considering both physiological and mental health as part of the treatment plan.

Implications for Clinical Practice

Modifiable health behaviors such as dietary interventions that include lower sodium foods, fewer processed foods, and more fruits, vegetables, and lean proteins have been related to clinically significant weight loss. For patients with obesity and hypertension, a Low Calorie Diet (LCD) or Very Low Calorie Diet (VLCD) that is built around healthy, non-processed, low sodium foods can lead to clinically significant weight loss. It is important to note, that health care professionals should focus on holistic patient care, paying attention to hypertension behavioral symptoms (e.g., depression, anxiety, and stress) while developing a treatment plan.

Sources:

1 Prevalence of obesity and severe obesity among adults: United States, 2017–2018

2 Heart disease and stroke statistics—2022 update: a report from the American Heart Association

3 The relationship between obesity and hypertension: an updated comprehensive overview on vicious twins

4 Differences in adherence to American Heart Association’s Life’s Essential 8, diet quality, and weight loss strategies between those with and without recent clinically significant weight loss in a nationally representative sample of US adults

5 Twenty‐year trends in the American Heart Association cardiovascular health score and impact on subclinical and clinical cardiovascular disease: the Framingham Offspring Study

6 Position of the Academy of Nutrition and Dietetics: interventions for the treatment of overweight and obesity in adults

7 Get quality nutrition from healthy food sources

8 Weight loss strategies for the prevention and treatment of hypertension

9 Association between psychological distress and hypertension: A systematic review and meta-analysis

10 Mental health in hypertension: Assessing symptoms of anxiety, depression, and stress on anti-hypertensive medication adherence