Individuals with prehypertension, a new blood pressure category defined as systolic blood pressure of 120–139 mm Hg and/or diastolic blood pressure of 80–89 mm Hg, are at an increased risk for heart diseases and are strongly recommended to practice lifestyle changes, including weight control. Data on impacts of long-term weight change on prehypertension are sparse.
To evaluate the association between weight change since age 20 and prehypertension risk.
In this cross-sectional analysis of 36 075 non-hypertensive women aged 40–70 years, information on weight history was collected at enrollment in the Shanghai Women's Health Study; blood pressures were measured 2–3 years later by medical professionals. The odds ratios (ORs) of prehypertension were calculated for women who gained or lost weight since age 20 compared with those with stable weight (gain or loss <5 kg), adjusting for age, lifestyle factors, sodium intake and body mass index at age 20.
A total of 47% of the study participants (n=16 981) had prehypertension. For a 6- to 10-kg gain, the OR (95% CI) was 1.36 (1.28–1.45); for 11- to 15-kg gain, 1.64 (1.54–1.75); for 16- to 20-kg gain, 2.32 (2.14–2.51); for 21- to 25-kg gain, 2.91 (2.60–3.26); and for a gain >25 kg; 3.65 (3.13–4.26). While for a 6- to 10-kg loss and a loss >10 kg, the respective ORs were 0.76 (0.67–0.87) and 0.47 (0.38–0.59). The increase in prehypertension risk associated with each 1-kg gain was similar to that associated with a 1-year increase in age. Although weight gain during early adulthood appeared to have a more pronounced effect on the risk of prehypertension, weight gain later in life also contributed significantly to an elevated risk.
Weight gain since age 20 substantially increases risk for prehypertension in non-hypertensive individuals, while weight loss significantly lowers the risk, emphasizing the importance of weight control throughout adulthood in preventing hypertension.
With improved understanding of the risk of high blood pressure and the course of the disease, a new blood pressure category ‘prehypertension’ was introduced in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) in 2003.1 Prehypertension is defined as systolic blood pressure of 120–139 mm Hg or diastolic blood pressure of 80–89 mm Hg. It has been demonstrated that damage to arteries begins at a fairly low blood pressure and worsens with age unless appropriate prevention strategies are taken. According to the JNC-7 recommendation, individuals with prehypertension should be, ‘firmly and unambiguously advised to practice lifestyle modification to reduce their risk of developing hypertension in the future’.1
Short-term weight loss has been shown in clinical trials to lower blood pressure.2 Whether weight control prevents primary hypertension in the general population remains to be established. A few studies have evaluated long-term weight change in relation to blood pressure,3, 4, 5, 6, 7 focusing primarily on subjects with hypertension or borderline hypertension and largely involving populations with a high prevalence of overweight and obesity.6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 There is a lack of data on the impact of weight change over time on blood pressure among normotensive individuals,4, 5, 17, 19 the target population for the primary prevention of hypertension. Given the observations that the relationship between blood pressure and cardiovascular disease is continuous and many blood pressure-related cardiovascular events are seen in individuals with high–normal or even normal blood pressure, it is important to identify modifiable factors that contribute to the rise in blood pressure among these normotensive individuals.1, 18 In China, studies have shown an increase in the prevalence of hypertension during the past decade, particularly in urban areas such as Shanghai.20, 21 The increased prevalence of hypertension can be attributed, to a large extent, to the increases in body weight in this population,20 in which, traditionally, the rate of obesity is low. In this report, we examined the association of prehypertension risk with weight gain and loss during different periods of adult life in relatively lean, non-hypertensive women in the Shanghai Women's Health Study.
Materials and methods
The Shanghai Women's Health Study, initiated in March 1997, is a population-based prospective cohort study of Chinese women aged 40–70 years at enrollment. Detailed study design and data collection procedures for the Shanghai Women's Health Study have been reported elsewhere.22 Briefly, the study recruited 74 942 women between 1997 and 2000 from seven urban communities of Shanghai, with a participation rate of 92.7%. All women completed a detailed baseline survey that was conducted in-person by trained interviewers using structured questionnaires. The questionnaires covered information on demographic characteristics, lifestyle and dietary habits, medical history (including a history of physician-diagnosed hypertension and use of antihypertensive medications) and weight history at ages 20 and 50, among others. Usual dietary intake over the previous 12 months was assessed for all the cohort members using a comprehensive, quantitative food-frequency questionnaire.22 All interviews were tape-recorded and selectively checked by quality-control staff to monitor the quality of the interview data. The study was approved by the relevant Institutional Review Boards for Human Research in China and the United States. A written informed consent was obtained from all study participants.
Anthropometric and blood pressure measurements
All anthropometric measurements, including weight, standing and sitting heights, and circumferences of the waist and hips, were carried out at enrollment according to a standard protocol by trained interviewers who were retired health professionals.23 All measurements were taken two times. A tolerance limit of 1 kg was set for weight measurement and 1 cm for height and circumference measurements. A third measurement was taken if the difference of the first two measurements was greater than the tolerance limit. The average of the two closest measurements was used in the analysis. In this study, weight change was calculated as the difference between current body weight measured at enrollment and recalled weight at age 20, between current weight and weight at age 50, or between weights at 50 and 20 years of age. Body mass index (BMI) was calculated as the subject's weight in kilograms divided by the square of height in meters. Waist-to-hip ratio was calculated by dividing the subject's waist circumference in centimeters by hip circumference in centimeters.
The first follow-up survey was conducted 2–3 years after the baseline survey, with a response rate of 99.7%. Blood pressure was measured for 91% of the participants (n=68 427) at their homes as part of the first follow-up survey. After the participants sat quietly for at least 5 min, trained interviewers (retired health professionals) measured blood pressure with the use of a conventional mercury sphygmomanometer according to a standard protocol.24
According to the JNC-7,1 subjects were classified into two categories: normal blood pressure (systolic blood pressure <120 mm Hg and diastolic blood pressure <80 mm Hg) and prehypertension (systolic blood pressure of 120–139 mm Hg and/or diastolic blood pressure of 80–89 mm Hg). Subjects with prehypertension were referred to as cases and those with normal blood pressure were referred to as controls in this analysis.
In this study, we excluded subjects who had a history of physician-diagnosed hypertension (n=20 826), coronary heart disease (n=5596), stroke (n=1514), or were receiving antihypertensive medications (n=12 032). We also excluded those who were found to have high blood pressure through the examination at the first follow-up survey (systolic blood pressure ⩾140 mm Hg (n=15 356) or diastolic blood pressure ⩾90 mm Hg (n=12 616)), or have an extremely low blood pressure (systolic blood pressure <80 mm Hg or diastolic blood pressure <50 mm Hg) (n=11). In addition, subjects who were pregnant at anthropometric measurement (n=10), had an extreme weight change (weight loss >30 kg or weight gain >60 kg) (n=11) or any missing data on anthropometric measurements (n=62), or reported an extreme salt intake (<1 or >20 g/day) (n=83) were also excluded. After these exclusions (not mutually exclusive), a total of 36 075 non-hypertensive subjects remained for the analysis of weight change since age 20. The analyses of weight change between age 20 and 50 and after age 50 were restricted to women >50 years of age.
In this cross-sectional analysis, age-adjusted means of weight change were determined using analysis of covariance with adjustment for age at blood pressure measurement. Multivariate-adjusted odds ratios (ORs) and their 95% confidence intervals (CI) for prehypertension in association with weight changes over time were estimated using unconditional logistic regression. Variables adjusted for in the multivariate analysis included age at blood pressure measurement (in years), education (four categories), household income (four categories), regular cigarette smoking (yes or no), regular alcohol consumption (yes or no), regular exercise (yes or no, participating in any kind of exercise at leisure time at least once a week for more than 3 consecutive months in the past 5 years), daily dietary sodium intake (five categories), and interval in years between anthrometric measurements at enrollment and blood pressure measurements 2–3 years later. Because blood pressure is characterized by diurnal variation, time at blood pressure measurement was also adjusted for in the analysis. Subjects whose current weight remained within ±5 kg of the value at age 20 were considered to have stable weight, serving as the referent category. ORs for prehypertension associated with each 1-kg weight change over an average of 5 years were also estimated in the multivariate models in which weight change was treated as a continuous variable. Sensitivity analyses were conducted by excluding subjects with a history of diabetes or cancer to evaluate the potential impact of obesity-related comorbidities on the association between weight change and prehypertension, or excluding tobacco users to evaluate the potential residual confounding effect of smoking on the association. All tests of statistical significance were based on two-sided probability.
The mean age of this study population was 48.6 (s.d.=7.6) years. The mean BMI was 23.1 (s.d.=3.0) kg/m2, with the prevalence rate of overweight (BMI ⩾25 kg/m2) and obesity (BMI ⩾30) being 23.7 and 2.1%, respectively. The mean values of systolic and diastolic blood pressure were 112.1 (s.d.=11.3) and 72.9 (s.d.=7.4) mm Hg. The mean value of dietary sodium intake assessed by a food frequency questionnaire was 2703 (s.d.=873) mg/day, which is about 15–25% lower than 24 h urinary excretion of sodium reported in studies conducted in southern China.25, 26 Of the study participants, 16 981 (47.1%) had prehypertension. Table 1 shows the mean values of weight change since age 20 according to selected current demographic and lifestyle factors. Body weight increased with aging, but the increasing trend peaked at 55 years of age and declined slightly thereafter. Subjects with greater weight gain were more likely to have higher household income and consume higher amounts of dietary sodium, but were less likely to use tobacco products or exercise regularly. Weight changes were not appreciably associated with education and alcohol consumption in this study population.
Table 2 shows the age-adjusted mean of weight change in prehypertensive cases and controls. The adjusted-mean weight change since age 20 in cases was significantly greater than controls (P<0.0001). Similar patterns were also found for weight change between 20 and 50 years of age and weight change after 50 years of age. Figure 1 displays multivariate-adjusted ORs of prehypertension in association with weight change since age 20. The ORs significantly decreased with weight loss but substantially increased with weight gain over time. The trend appeared to be monotonic and approximately linear (P for trend <0.0001). Compared to women who maintained a relatively stable weight since age 20 (loss or gain <5 kg), women who lost >10 kg had a 53% reduction in risk of prehypertension (OR=0.47; 95% CI 0.38–0.59), whereas women who gained >25 kg had a risk approximately four times as high (OR=3.65; 95% CI 3.13–4.26).
Table 3 shows ORs for prehypertension associated with each 1-kg increase in weight and 1-year increase in age since age 20. After controlling for BMI at 20 years of age and other potential confounding factors, a 1-kg increase in weight was associated with a 5% increase in risk of prehypertension (OR=1.05; 95% CI 1.05–1.05). The risk estimate was slightly attenuated when further adjusting for current waist-to-hip ratio (OR=1.04; 95% CI 1.04–1.05). Additional adjustment for dietary factors including total fat, carbohydrate, protein, calcium, potassium, magnesium, vitamin C, total vitamin E and folic acid, did not appreciably alter the results (data not shown). Interestingly, in the same statistical model, each 1-year increase in age was also associated with a 5% increase in risk of prehypertension (Table 3). The positive associations with prehypertension were also found for weight gain both before and after 50 years of age, although the magnitude of the association appeared stronger for weight gain during early adulthood.
We conducted further analyses stratified by age, BMI at age 20 and current BMI and waist-to-hip ratio to explore whether the association between weight change and prehypertension was modified by these covariates (Table 4). Regardless of BMI at age 20, weight gain was associated with a significantly increased risk. In contrast, weight loss was associated with a significantly reduced risk among women with a BMI ⩾19.6 kg/m2 at age 20 only. No significant effect was observed for weight loss among those with a BMI <19.6 at age 20, possibly because significant weight loss among these women was very uncommon (0.25%). There was no evidence for effect modification by current BMI and waist-to-hip ratio. We also conducted analyses excluding those who had regularly consumed tobacco products or alcoholic beverages or who had a history of diabetes or cancer and found no material changes in risk estimates.
To evaluate potential timing effect of weight change during early (between 20 and 50 years of age) and later adult life (after 50 years of age), we did additional analyses by using an average 5-year weight change instead of the overall changes among women ⩾55 years of age. Weight gain during early adulthood appeared to have a more pronounced effect on the risk of prehypertension. Each 1-kg increase in weight every 5 years during the early adulthood was associated with an OR of 1.29 (95% CI 1.24–1.36); the corresponding OR for each 1-kg increase in weight every 5 years during the later adulthood was 1.06 (1.04–1.08). Both associations were independent of the initial body weight (weight at 20 or 50 years of age; Table 5).
In this study of relatively lean, non-hypertensive women, we found that weight gain throughout adulthood was associated with a remarkably increased risk of prehypertension. Each 1-kg increase in weight was associated with a 5% increase in risk of prehypertension, which was comparable to the effect of a 1-year increase in age on the risk. Weight loss, on the other hand, was related to a significantly reduced risk. These associations were independent of age, lifestyle and dietary factors and BMI at age 20.
Weight changes over time have been considered a useful measure for assessing health risks associated with body fat because, ‘they take into account individual differences in frame size and lean mass that are difficult to measure’.27 Numerous epidemiologic studies4, 5, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39 and interventional trials2, 40, 41, 42 have demonstrated a major role for excess body weight in determining hypertension risk. Few studies, however, have evaluated the impact of long-term weight change on hypertension risk, particularly among normotensive adults.4, 5 The Framingham Study recently reported that sustained weight loss was associated with a significantly reduced risk of hypertension.4 The beneficial effects of weight loss on hypertension were also found in the Nurses Health Study.5 In contrast, adult weight gain substantially increased the risk of hypertension.5 Little is known about the influence of weight change during adult life on the risk of prehypertension. To our knowledge, our previous report from the Shanghai Men's Health Study is the first one that has evaluated the association between long-term weight change and prehypertension risk.19 In that study, blood pressure significantly increased with weight gain among non-hypertensive men. Men who gained 17.2 kg since age 20 (the highest quintile) had a fourfold increased risk of prehypertension compared with those having a weight gain ⩽2 kg (the lowest quintile), which was comparable to the results observed in the present study of non-hypertensive women.
Age-dependent effects of weight change on hypertension risk have been suggested in previous studies.4, 5 In the Nurses Health Study,5 the protective effect of weight loss was found to be more pronounced in younger women (<45 years). Controversially, the beneficial effect appeared most prominent in elderly adults (>50 years) in the Framingham Study.4 In the current study, a stronger association between weight change and prehypertension risk was suggested for younger women (<55 years). Differences in study population, design, blood pressure and anthropometric measurements and cutoff points for categorization of weight change may have contributed to some of the inconsistencies. Differences in the study time frame of weight changes (fixed time frame with various starting age4 vs fixed starting age with various time frame5) may also be an important contributor.
In the present study, to better understand the timing effect of weight change throughout adulthood, we analyzed the associations of each 1-kg increase in weight every 5 years during the early and later adulthood with the risk of prehypertension among women ⩾55 years of age. We found that risks of prehypertension increased with weight gain regardless of when the weight gain started. However, the magnitude of the association with weight gain during early adulthood (between age 20 and 50) was greater than that during later adulthood (after age 50). These observations emphasize the importance of weight control throughout adulthood in preventing hypertension and the need to take preventive actions early.
The current study has several notable strengths. The large sample size, population-based study design and extremely high response rates minimized potential selection bias. Home blood pressure measurement by medical professionals was used in this study, which has been repeatedly shown in the previous studies to have, ‘a better prognostic accuracy than office blood pressure measurement’.43 Furthermore, very few women in our study smoked cigarettes or drank alcoholic beverages, which substantially limited the potential confounding effects of these variables on the association of prehypertension and weight change.
Some methodological limitations of the study should be addressed. The recall accuracy of weight history during early adulthood, which has not been validated in this study, is a concern. Previous studies have shown that heavier people tend to under-report their weight to a greater extent than normal weight people.44 Because information on weight history was collected before blood pressure measurement, potential recall bias is likely to be random, which would likely attenuate the true association between weight change and prehypertension.
Individuals in the different categories of weight change are also likely to differ in several other respects, such as certain lifestyle and dietary factors. Although careful adjustment for these potential confounding factors had been made, we could not completely rule out the possibility of residual confounding because of unmeasured or inaccurately measured covariates. For example, information on family history of hypertension was not collected in the study. People with a family history of hypertension are likely to pursue a healthy lifestyle. In addition, a large weight loss may result from the presence of serious comorbidities. However, we adjusted for a broad range of potential confounding variables and excluded those with a history of cardiovascular disease in our primary analyses. Further controlling for other potential confounders, including lifestyle and dietary factors, and excluding subjects with histories of diabetes and cancer in sensitivity analyses did not alter the results materially, suggesting that the potential residual confounding is unlikely to explain away the observed robust association between prehypertension and weight change. The use of blood pressure values measured on a single occasion is another limitation. However, several studies have shown that a single blood pressure reading can be a strong predictor for future cardiovascular events.45
In summary, our study provides strong evidence for a graded positive association between weight gain and risk of prehypertension. Gaining 1 kg of weight during adulthood may have an effect that approximates the effect of a 1-year increment in age on the development of prehypertension, while weight loss is associated with a substantial reduction in the risk. Although aging is unavoidable, our study suggests that, if a woman could avoid a 1-kg weight gain during adulthood, she would slow down 1 year of ‘aging’ on her risk of developing prehypertension. Therefore, it cannot be overemphasized that weight control in early life and throughout adulthood should receive top priority in prevention of prehypertension and overt hypertension.
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We are grateful to the participants and research staff of the Shanghai Women's Health Study for their contribution to the study. We also thank Ms Brandy Sue Bentley for her assistance in preparing the manuscript. This work was supported partially by USPHS Grant R01CA70867.
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Yang, G., Shu, X., Gao, Y. et al. Impacts of weight change on prehypertension in middle-aged and elderly women. Int J Obes 31, 1818–1825 (2007) doi:10.1038/sj.ijo.0803680
- blood pressure
- weight change
- odds ratio
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