REVIEW ARTICLE

Overweight and Hypertension

A Review
By BENJAMIN N. CHIANG, M.D., LAWRENCE V. PERLMAN, M.D.,
AND FREDERICK H. EPSTEIN, M.D.

SUMMARY
The interrelationships between hypertension and obesity, two common and major
health hazards, are reviewed. Comparisons of simultaneous intra-arterial and cuff blood
pressure measurements indicate in general that the association between blood pressure
and body weight is real and independent of arm circumference. Hypertension is more
common among the obese than among the nonobese and, conversely, a significant
proportion of hypertensive persons in the population are overweight. Obese hypertensive
subjects experience a greater risk of coronary heart disease than the nonobese, and
mortality rates for obese hypertensive persons are higher than for those with obesity
alone or hypertension alone. Weight reduction has been shown to lower blood pressure,
and it may bring about a more favorable prognosis in obese hypertensive persons. Pos-
sible mechanisms that may be responsible for the frequent association between obesity
and hypertension have been discussed. Irrespective of the underlying pathophysiologic
mechanisms, the adverse metabolic and hemodynamic effects of obesity upon hyper-
tension impose an extra burden and strain on the circulatory system and compromise
its functional adequacy. Although it is not precisely known to what extent weight
reduction alone may be effective in controlling or preventing the lesser degrees of
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hypertension, the control of obesity should be an intrinsic part of any therapeutic or

preventive antihypertensive regimen.

Additional Indexing Words:

Obesity Blood pressure measurement Hypertension Hemodynamic effects
Epidemiology Adrenocortical steroids Weight reduction Prognosis

E LEVATED blood pressure and obesity
predispose to coronary heart disease.1 2
The control of these two factors is, therefore,
an essential part of any coronary heart disease
prevention program. It is likely that the detri-
mental effect of obesity is mediated, at least
in part, by the association between blood
pressure and weight levels. In fact, the fre-
quent coexistence of these two common con-
From the Department of Epidemiology, School of
Public Health, University of Michigan, Ann Arbor,
Michigan.
Dr. Chiang is a recipient of an International
Postdoctoral Research Fellowship (5 FOJ-TW 1025)
and Dr. Epstein is the recipient of a Research
Career Award (HE-K6-6748) from the U. S. Public
Health Service, Bethesda, Maryland.
Circulation, Volume XXXIX, March 1969
ditions suggests that there is a causal relation
between them so that weight gain constitutes
one kind of environmental stress that brings
a genetic predisposition toward hypertension
into the open. A parallel situation exists in the
case of diabetes, which may sometimes be
controlled by weight reduction, implying that,
conversely, overeating can precipitate it.
To prevent coronary heart disease, there
must be a constant search for environmental
factors that may be modified to delay the on-
set and progression of atherosclerosis and its
consequences. The present review attempts to
summarize some of the key evidence that
links hypertension and obesity and to provide
a scientific basis for the belief that weight
control is likely to be an important ingredient
403
 404
of any program for the control of hyperten-
sion in the community and in individual pa-
tients.
Prevalence of Overweight and Hypertension
In the United States about 30% of men and
40% of women over the age of 30 are 20% or
more above "desirable weight" as defined in
the tables published by the Metropolitan
Life Insurance Company.3 The 1959 Build and
Blood Pressure Study of the Society of Actu-
aries showed that 6% of men (ages 15 to 69)
and 11% of women (ages 15 to 69) were 20% or
more in excess of "average weight" (for height
and age).4 The difference in the percentage
of persons 20% overweight by one of these
standards depends obviously on the definition
of overweight and the standard used.
Weight is gained more frequently at certain
ages or physiological periods. In women, this is
most likely after the completion of growth-
about age 20, during pregnancy, and after the
menopause.5 Men tend to gain weight between
the ages of 25 and 40 years.6 It has been
shown that persons overweight as children,
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teenagers, or young adults are likely to remain
or become more overweight throughout life.'
Overweight, as defined above, is the ratio
of actual weight to average or desirable
weight (specific for age, sex, height, and body
build).4 An individual may be overweight on
account of musculature or bony structure
rather than excess fat, so that overweight and
obesity are not necessarily synonymous. Aver-
age weight tables for men and women aged
15 to 65 years are provided in the 1959 Build
and Blood Pressure Study of the Society of
Actuaries.4 Desirable weight tables have been
constructed by the Metropolitan Life Insur-
ance Company,3 derived from the 1959 Build
and Blood Pressure Study. The National Cen-
ter for Health Statistics, Public Health Service,
has published data on height, weight, and
selected body dimensions based on a nation-
wide adult population sample instead of an
insured population.6' 7
Since the component of overweight that
can be reduced is fat, determination of rela-
tive fatness is of practical significance. Obesity,
CHIANG ET AL.
defined as excessive body fatness, can be
measured in many ways. Some methods are
quite complex, such as densitometer or
hydrometry studies and determination of whole
body potassium content; others are relatively
simple, including measurement of subcutane-
ous skin folds, and soft-tissue x-rays.8 16 The
Committee on Nutritional Anthropometry
recommended triceps and subscapular skin-
folds as methods for characterizing over-all
fatness'4 since subcutaneous fat makes up
half of the total body fat content.17 For prac-
tical purposes, triceps skinfold measurements
alone are considered adequate as being sim-
ple, reasonably precise, and reproducible.16
Beyond 9 years of age, fat accounts for a high-
er percentage of total body weight in females
than in males. Body fatness for both sexes
increases with age and, in adult life, increases
at a faster rate for men than women; yet,
women at all ages are on the average fatter
than men. The extent to which overweight
measures obesity depends on the correlation
between these two measurements, which
varies according to body build. The level at
which obesity assumes clinical and prognostic
significance is not easy to define. Much of
this information comes from insured popula-
tions and cannot be easily extrapolated to
the population at large. It would probably
be conservative to estimate the prevalence
of significant obesity in the United States, de-
pending on age and sex, as being at least
somewhere between 20 and 30%.
The prevalence of hypertension, like the
prevalence of obesity or overweight, depends
on the level one chooses as the line of division
between "normal" and "abnormal." If a systolic
blood pressure of 160 mm Hg or greater and/
or diastolic blood pressure of 95 mm Hg or
greater are chosen,'8 data from the Tecumseh
Study indicate that 27% of men and 37% of
women aged 40 to 59 are "hypertensive."'9
Relationship between Blood Pressure
and Body Weight
In this section, three questions will be dis-
cussed: (1) what is the over-all correlation
between blood pressure and body weight,
Circulation, Volume XXXIX, March 1969
 OVERWEIGHT AND HYPERTENSION
(2) what proportion of hypertensive persons
are overweight, and (3) is the correlation
between blood pressure and body weight a
methodologic artifact?
Correlations between Blood Pressure
and Body Weight
Clinical and epidemiological investigations
of the relationship between body weight and
blood pressure from different parts of the
world are summarized in table 1. Most popu-
lation studies tend to show a rise of blood
pressure with increase of body weight or
adiposity. The correlation tends to be higher
in countries where obesity is more common.
Epstein reviewed geographic differences in
various parts of the world, classified the age-
blood pressure trends into groups according
to the slope of pressure rise with age and
suggested that populations who show the least
rise of blood pressure with age are those with
lower average weight.20 Several studies that
do not show a constant relationship between
body weight and blood pressure have been
reported from primitive societies or in social
groups where either the range of body weight
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is narrow or hypertension is rare.20 24 Seasonal
variation of blood pressure must be taken into
account, at least in subarctic climates, where
seasonal changes in skinfolds were correlated
with variations in blood pressure.25
The magnitude of the association between
blood pressure and body weight in countries
where obesity is very common as in the United
States, or common as in Scandinavia, may
be illustrated by data from four studies. In
the Tecumseh Study26 in Michigan, the cor-
relation coefficients between systolic pressure
and relative weight were 0.29 for those aged
20 to 29; 0.33 for the group aged 30 to 39;
0.23 for those 40 to 49; and 0.21 for those
50 to 59; in the older age groups 60 to 69 and
70 to 79 correlation coefficients were only
0.13 and 0.05 respectively. For diastolic blood
pressure26 correlation coefficients were highest
for those aged 30 to 39 (0.32) and lowest
for those aged 60 to 69 (0.05); for the other
age groups, the values were 0.28 (20 to 29),
0.25 (40 to 49) and 0.26 (50 to 59). In the
Framingham study in Massachusetts, the cor-
Circulatioin, Volume XXXIX, March 1969
405
relation coefficient between systolic blood
pressure and relative weight at ages 30 to 59
was 0.3 for both sexes.27 In an extensive
Scandinavian study,28 the blood pressure
difference between those 20% underweight and
those 20% overweight averaged 16.9 mm Hg
for systolic and 9 mm Hg for diastolic pressure
(11,063 men and 3,721 women, age 20 to
60). In another large study by Boe and his
colleagues,29 in Norway, among 67,976 adult
men and women, there was an increase in
systolic and diastolic pressure of 3 and 2 mm
Hg, respectively, for a 10 kg increase in body
weight.
The relationship between blood pressure
and body weight has been shown to be greater
in women,26, 33, 34 in those with a family his-
tory of obesity and hypertension,35 36 in the
extremely obese,33 37 38 and in those less than
60 years old.21 22 27 Systolic blood pressure
shows a greater association with body weight
than diastolic pressure.35 39 Higher blood
pressure was found in nonsmokers than smok-
ers who are less heavy.40 In other studies,
hypertensive patients were heavier than nor-
motensive controls.41 42 In addition, relative
weight was correlated significantly with the
prevalence of hypertensive retinopathy,41 as
well as cardiovascular complication in hyper-
tensive patients." 41 Blood pressure has been
shown to correlate with the ponderal index43
and skin fold thickness.27 Both Whyte2' and
Kannel and his associates27 have noted blood
pressure to be more strongly and primarily
correlated with body weight rather than body
fat and concluded that the correlation with
body fat is a secondary phenomenon due to
the association between weight and degree of
fatness.
It is of interest that in at least one popula-
tion in which hypertension and obesity are
both very common, no correlation between
the two variables was found; these findings
from a study among American Negroes in
South Carolina,30 remain to be explained and
confirmed by other investigations. In the Evans
County (Georgia) study, blood pressure was
found to be higher in Negro women, but not
in men with higher body weight.3' Miall and
 406 CHIANG ET AL.
Table 1
Relation of Body Weight and Blood Pressure
Senior
author Study population Significant findings
Larimore 417 factory workers; The asthenic had the lowest blood pressure;
1923* B.P. and body build the sthenic had the highest blood pressure
(44)t
Marks Metropolitan Life Insur.; B.P. 7/6 mm Hg higher in persons 25% over-
1924 men age 28-42 years, U.S.A. weight; overweight had higher blood pressure
(45)
Huber 1,332 healthy military 2/3 of persons over age 40 with 10 lbs. over-
1927 personnel, U.S.A. weight or more had elevated blood pressure;
(46) 49% of those 10% underweight or more with
low systolic pressure of 110 mm Hg or less;
18% of those overweight with high systolic
blood pressure over 140 mnm Hg
Hartman 2,042 persons age over 15 Systolic B.P. increases with increase of weight
1929 years, males, 959; females, in both sexes; diastolic B.P. increases with
(39) 1,083; Mayo Clinic increase of weight in females only
Robinson 10,883 healthy persons; Obese females and males have 6 and 12 times
1939 7,478 males, 3,405 females, more hypertension respectively; B.P.
(33) U.S.A. increases with overweight, and low in under-
weight in all age groups of both sexes
Short 3,516 healthy persons More hypertension among overweight persons;
1939 applying for periodic B.P. difference of 11/4 mm Hg between
(47) health examination; U.S.A. overweight and underweight in the 50-59 age
group
Boynton 75,258 University students Mean systolic and diastolic B.P. rises as weight
1948 (U. of Minnesota), increases in each age group; more marked
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(35) 43,800 males, 31,258 females in systolic B.P.; systolic B.P. higher in
persons with positive family history
Green 1,260 obese patients Hypertension more frequently noted in mild
1948 age 11-70, U.S.A. to moderate overweight; age distribution of
(48) obese hypertension did not differ from
essential hypertension in general
Master 1,000 private patients In males, more hypertension in overweight
1953 age20-64; 169 with than the general population, ratio: 32 :14; in
(49) hypertension females, no difference in hypertension
Thomas 266 Johns Hopkins Medical Family study showed high correlation between
1955 students; study of family hypertension and obesity among parents,
(36) relation of overweight and grandparents, uncles, and aints
hypertension
Bjerkedal 14,784 adult population, Small increase of mean systolic and diastolic
1957 11,063 males, B.P. with increase of relative weight in all age
(28) 3,721 females, Norway groups; no excessive accumulation of
hypertension in overweight persons
Boe 67,976 adult population, Overweight has negligible effect on hyper-
1957 27,718 males, 40,258 females; tension; 3/2 mm Hg increase in systolic-
(29) Bergen, Norway diastolic pressure for each 10 kg increase of
body weight

Circulation, Volume XXXIX, March 1969

 OVERWEIGHT AND HYPERTENSION 407
Table (continued)
Relation of Body Weight and Blood Pressure
Senior
author Study population Significant findings
Padmavati 1,132 low socioeconomic; In low S-E class, B.P. rise with body weight,
1959 224 high socioeconomic; but not with age; in high S-E class, B.P.
(50) Delhi, India rises with both weight and age; systolic
pressure rises 0.2-0.3 mm Hg per pound weight
increase, diastolic 0.2 mm Hg per pound
weight increase in both groups
Build & B.P. Metropolitan Life Insurance Excessive mortality of overweight persons esp.
Study 4,900,000 policy holders, in younger age group, male sex and
1959 U.S.A. hypertensive; mortality mainly due to
(4) cardiovascular causes
Nutrition 1,333 military personnel Both systolic and diastolic pressures
Survey of age 20-49, Philippines increase with each increinent of relative
Armed Forces weight
1960
(52)
Stamler Peoples Gas Co. employees, Twofold increase in hypertension in over-
1961 1,329 men age 40-49; weight persons than in underweight persons
(51) Chicago, Ill., U.S.A.
Epstein 8,641 adult population, Significant correlation between B.P. and
1965 age 20-79; relative weight and skin folds; hypertensive
(26) Tecumseh, Michigan, U.S.A. heart disease significantly correlated with
relative weight in females only
Doyle Waterside worker, B.P. rises with skinfolds in younger age, up
1961 Australia to 40 years; not in older people over 60 years
(53)
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Hunter Polynesians, Cook Island Significant correlation between obesity and

1962 hypertension and hypercholesteremia but
(55) coronary heart disease is rare
Truedsson Healthy individuals, Skin folds correlate with blood pressure in
1962 Sweden females, but not in males
(34)
Palmai Subarctic area Seasonal changes of B.P. correlation with
1962 study of seasonal variation changes of subcutaneous skinfolds
(25) of B.P.
Whyte 100 healthy men B.P. correlates significantly with bulk in
1959, 1965 20-24 years, young Australians, no correlation in older
(21, 22) Australia Australians. In New Guinea, B.P. does not rise
with age, not related to relative weight;
people are lean.
Reid 676 van drivers of B.P. of nonsmokers higher than smokers;
1966 General Postoffice age 40-59, the body weight is also higher in the non-
(40) England smokers
Shaper Three east African tribes, B.P. no rise with increase of age or weight in
1967 Northern Kenya two tribes, the third tribe showed B.P. increase
(23) with weight, also increased prevalence of
hypertension; the last tribe showed increased
ponderal index and consumed more carbo-
hydrates

Circulation, Volume XXXIX, March 1969

 408 CHIANG ET AL.
Table 1 (continued)
Relation of Body Weight and Blood Pressure
Senior
author Study population Significant findings

Boyle 2,184 persons, B.P. rises with increase of weight in white

1967 Charleston Heart Study, people, but no significant difference in
(30) U.S.A. weight/B.P. relation in Negro population
who have more hypertension
McDonough 3,102 subjects age 15-74, More hypertension in Negro population than
1967 Evans County, Ga., U.S.A. white. In the Evans County (Georgia) study
(31) blood pressure was found to be higher in Negro
females, but not males with higher body
weight
Chiang Taiwan Cardiovascular Hypertensive subjects average 5 kg heavier
1967 Study, 1,822 men age 40-59, than age-matched normotensive controls; the
(42) Taiwan hypertensives have significantly thicker skin-
folds
Tibblin Hypertension, 855 men, B.P. correlated with obesity; hypertensive
1967 age 50, Goteborg, Sweden retinopathy and LVH more in the obese
(41) group (3-fold increase)
Keys Cooperative study B.P. significantly correlates with skin folds
1967 in 7 countries except Serbian village of Velike Krsna,
(24) Men, age 40-59 where there was no correlation; the men
are underweight and thin
Kannel The Framingham study, More hypertensives in the overweight men
1967 5,127 men and women and women; B.P. correlates with relative
(27) age 30-62, U.S.A. weight throughout all age groups (30-62)
Aleksandrow 10% of adult population, B.P. rises with weight increase; more
1967 Poland hypertension in obese group
(54)
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* Date of publication.
t Reference numbers are in parentheses.
his associates32 have made a careful analysis
of the relation between blood pressure and
body weight, based on a large population
sample in South Wales; a correlation was
confined to younger persons, in accordance
with a similar tendency already noted above
in the Tecumseh population.26 Their state-
ment32 that the cause and effect relationship
between the two parameters needs further
investigation is well justified. In the meantime,
summarizing the data presented in this sec-
tion, the evidence is overwhelmingly in favor
of the view that blood pressure and body
weight are positively correlated.
Frequency of Overweight among
Hypertensive Persons
According to most reports, overweight oc-
curs more frequently in hypertensive than
normotensive subjects.21 26, 29-36, 39, 42, 44-5 In
the Framingham study, the over-all prevalence
of "obesity," defined as a "Framingham Rela-
tive Weight" of 120 or greater (that is, 20%
above the height and sex-specific median),
was about 9% among men aged 30 to 59. From
the data presented, it may be calculated that
about 6% of the men were hypertensive, ac-
cording to the definition used. Among these
men, the prevalence of obesity was between
13 and 19%, depending on age, whereas the
prevalence of obesity among normotensive
controls (disregarding borderline hypertensive
subjects in the population) varied between
2 and 4% in this age range. A similar trend has
been demonstrated in the Tecumseh Com-
munity Health Study.26 In the latter study,
33% of the participants (both sexes, age 40
to 59) in the upper quintile for blood -pres-
sure were in the upper quintile for relative
weight.26 43 Overweight women generally
have more hypertension than overweight men.
Robinson and associates,:33 in a study of 10,833
persons, showed that obese women have hy-
pertension 13D times more often than obese
men.
Circulation, Volume XXXIX, March 1969
 OVERWEIGHT AND HYPERTENSION
The frequency of overweight among hy-
pertensive persons will obviously vary ac-
cording to the definitions used for these two
variables. Using definitions that, from the
public health point of view, are neither too
liberal nor too conservative, one may estimate
that at least between one fifth and one third
of all hypertensive subjects in the adult popu-
lation are overweight. Since such persons have
an increased mortality from cardiovascular
and cerebrovascular diseases, this fact has
preventative implications as far as blood pres-
sure lowering through weight reduction is con-
cerned, as will be discussed later.
Comparison of Direct Intra-Arterial
and Indirect Auscultatory Methods
for Blood Pressure Measurement
Most observers agree that blood pressure
increases with body weight or skin folds. The
problem is whether the increase is true or an
artifact resulting from the influence of large
arm girth, thick subcutaneous fat, or both.
Ragan and Bordley56 compared 51 per-
sons by simultaneous measurement of intra-
arterial blood pressure in one arm and the
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indirect auscultatory method in the other; 13
of the 51 cases had aortic insufficiency; it was
found that indirect blood pressure tended to
be lower than the direct readings for subjects
with thin arms and higher for subjects with
thick arms. Pickering and his colleagues57
used the same data, excluding the 13 cases
with aortic insufficiency, to draw up a regres-
sion equation and a table for correction of the
indirect sphygmomanometer readings. Miall
and Oldham58 used this equation for correct-
ing cuff readings by arm circumference in an
epidemiological study but also showed a high
correlation between arm circumference and
weight (r = 0.99). In 1952, Bjerkedal28 studied
the blood pressure of 14,784 adults in Norway.
He found a small increase of blood pressure
with body weight and an excess of hyperten-
sion in obese persons, concluding that this
effect was due to the influence of arm girth
as postulated by Ragan and Bordley,56 and
Pickering and associates.57 However, careful
review of his paper indicates that there are
more individuals with substantially increased
Circulation, Volume XXXIX, March 1969
409
blood pressure than could be expected from
the small artifact attributed to increased arm
girth.
Recent studies by Raftery and Ward59 and
Holland and Humerfelt,60 comparing the di-
rect intra-arterial and indirect auscultatory
blood pressures failed to confirm the observa-
tions of Ragan and Bordley; the difference
between intra-arterial and cuff blood pressure,
on the one hand, and arm circumference or
skinfold thickness, on the other, were not
correlated but a significant correlation be-
tween arm circumference and the direct arteri-
al pressure was found. Berliner and co-work-
ers61 studied simultaneous intra-arterial and
indirect cuff blood pressure of 100 subjects,
61 were obese and 39 nonobese. While the
indirect method generally, but not consistent-
ly, underestimated systolic and overestimated
diastolic pressure, among lean and moderately
obese persons the discrepancies were usually
of a minor degree; even in the extremely
obese persons, large arm girth did not regular-
ly cause falsely high readings so that a correc-
tion for arm circumferences could not be ap-
plied routinely. Similar studies by Karlefors
and his associates62 and Nagle63 showed good
agreement between indirect and direct blood
pressures at rest and during exercise. Kannel
and associates,27 in the Framingham study,
compared upper arm and forearm pressures in
the same persons and found similar readings
whether or not their arm girths were large.
Alexander37' 3 studied a group of grossly
obese patients with average weight over 300
pounds with simultaneous direct intra-arterial
and indirect cuff pressure measurement; the
blood pressure agreed to within 20 mm Hg
systolic and 10 mm Hg diastolic on half of the
occasions, and the cuff method gave false low
readings as frequently as high readings; most
of the patients were frankly hypertensive on
the basis of intra-arterial readings. Reid and
co-workers,40 in a survey of British postal
workers, found no significant partial correla-
tion between blood pressure and arm circum-
ferences. Khosla and Lowe64 observed from a
regression analysis of systolic and diastolic
pressure, age, weight, and arm circumference
 410
in a population sample of employed men
aged 45 to 69 years that the relationship
between arm circumference and sphygmo-
manometer reading is indirect and due to
the high correlation of arm circumference with
body weight, which, in turn, is related to blood
pressure. Lowe65 analyzed indirect blood
pressure readings in a population of over
5,000 employed men, aged 15 to 69 years; he
found that, for a given age, sphygmomanome-
ter readings increase with body weight and
that weight and arm circumference are highly
correlated. When the blood pressure is cor-
rected for weight, the effect of arm circum-
ference upon blood pressure is negligible.
Karvonen66 and later King67 have suggested
that discrepancies between direct and indirect
readings could be minimized by using a wide
cuff in obese individuals.
Tibblin,4' in a cohort study of hypertension
in men, found body weight and skinfolds not
only related to the level of blood pressure, but
also to the severity of hypertensive retinopathy.
The prevalence of subjects with hypertensive
eye-ground changes increased about three
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times, with an increase in subscapular skin-
folds and body weight; the fundus changes
were independent of arm circumference.
Stamlerl also found body weight to be cor-
related not only with blood pressure, but also
with hypertensive heart disease, as demon-
strated by electrocardiographic or x-ray evi-
dence of cardiomegaly.
In summary, sources of variation in measur-
ing blood pressure by the indirect sphyg-
momanometer method, as pointed out by Rose
and others,68 are multiple, arm circumference
being only one source of possible variation in
the recording of blood pressure. Recent studies
on the effect of arm circumference on pressure
readings appear to have shown that the dis-
crepancy is minor in the majority of cases,
and the difference between direct intra-arterial
and indirect cuff readings varies in either
direction in obese as well as nonobese sub-
jects (table 2). The relationship between arm
girth and sphygmomanometer pressure read-
ings is likely to be an indirect one due to high
correlation between body weight and arm
CHIANG ET AL.
circumference, so that the cuff blood pressure
reading should not be corrected for arm
circumference. Correcting blood pressure by
arm circumference will obscure the important
influence of body weight on blood pressure in
epidemiological studies. ' 41, 61, 62, 64 Further-
more, it is concluded that the relationship
between body weight and blood pressure is
not a methodological artifact, due to falsely
high blood pressure readings in heavier per-
sons with fatter arms.
Overweight as a Risk of Developing
Hypertension and Hypertensive Heart
Disease: Longitudinal Studies
Few longitudinal studies on the relation of
overweight and the risk of subsequent hyper-
tension have been published.27 6972 Levy and
his colleagues69-71 did a retrospective study of
the medical records of 22,741 officers in the
United States Army. An officer was considered
to be overweight if he was heavier by 20
pounds or more than the standard given in
Army regulations. Two and a half as many
men developed sustained hypertension in the
overweight as compared to normal controls
after the age of 45 in a total experience of
33,921 persons-years. When transient tachy-
cardia and transient hypertension were added
to overweight, the ratio of subsequent develop-
ment of sustained hypertension was 12.3 fold.
The ratios of retirement and death from
cardiovascular-renal diseases for the same
group were 4.1 and 2.0 times higher, respective-
ly, than for the normal controls.69' 70, 71
Stamler72 analyzed data on 746 men in the
labor force of a Chicago utility company
over a period of 20 or more years. A strong
relationship between the incidence of hyper-
tensive disease in middle age and the rate of
increase of body weight in a 20-year period
was shown. Men at desirable weight as young
adults and exhibiting little or no weight gain
over the ensuing decades had the lowest in-
cidence rate of hypertensive disease, whereas
men above desirable weight as young adults
and with significant weight gains over the
next 20 years had a 4 to 5 fold higher inci-
dence rate of hypertensive disease. In another
group of 594 employees of the same company
Circulation, Volume XXXIX, March 1969
 OVERWEIGHT AND HYPERTENSION 411

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 412
Table 3
Effect of Weight Reduction on Blood Pressure
Senior
author Study group
Benedict 25 normal men studied; on
1918* low calorie diet until 10-12%
(86) weight loss, then maintained
reduced weight
Preble 1) 194 obese patients, wt.
1923 loss at least 10 lbs.
(87) 2) 1,000 cases, with 62 hyper-
tension, B.P. over 200 mm
Terry 63 obese patients, mean age
1923 45, mean wt. 199 lbs. 58%
(88) with hypertension, mean B.P.
196/103 mm Hg; on 1,200
calorie diet for 1 yr.
Bauman 183 obese patients, on low-
1928 calorie and low-salt diet,
(89) observed for 9.8 months
Master 91 females and 8 males from
1929 obesity clinic, 10-58 years of
(78) age, wt. 170-225 lbs; 67%
with systolic pressure over
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150 mm Hg
Fellows 294 obese Metropolitan Life
1931 Insurance Co. employees, on
(90) 1,200 calorie diet; in 18
cases thyroid was added
Wood Animal experiment
1939 8 dogs: 4 normal, 4 with
(74) experimental hypertension
Evans 100 consecutive obese
1952 patients, 61 are hypertensive
(82) (systolic B.P. 140-180
mm Hg)
Fletcher 38 obese hypertensive females
1954 (20% overweight or more),
(81) B.P. over 150 systolic and/or
100 diastolic mm Hg. Initial
diet 600 calories/day, later to
1,000 calories/day. Average
CHIANG ET AL.
Results
B.P. drop observed in 11 men. Average B.P.
drop from 120/83 to 102/69 mm Hg. 3
borderline hypertension: B.P. before weight
loss 142/90, 130/90, 120/90; after weight loss
B.P. on 22nd day: 100/65, 100/70, 90/70
mm Hg
There was uniform B.P. drop with wt. loss;
Mean B.P. drop 154/96 to 133/86 mm Hg;
after weight loss, mean B.P. drop from
219/129 to 170/108 mm Hg
One year after weight reduction, mean B.P.
drop from 196/103 to 170/95 mm Hg
48 out of 101 with significant systolic B.P.
reduction; 72 out of 161 with significant
diastolic B.P. reduction
Wt. reduction associated with B.P. drop,
(more marked with systolic pressure), also with
slowing of heart rate. In 53 patients, wt. loss
25-30 lbs., B.P. drop from 20-30 systolic and
15-20 diastolic. Regain of wt. followed rise of
B.P. Wt. loss also associated with improved
exercise tolerance
Weight loss associated with significant B.P.
drop; 30 hypertensives showed favorable
course 5 years after weight reduction.
75% of 294 with initial weight loss. 5 years
later, 193 re-examined, only 21% maintained
low weight, 79% regained weight in whole or
part
Marked rise of systolic blood pressure when
caused to gain large amount of wt. by feeding a
diet composed of beef fat in both normal and
hypertensive dogs. B.P. drop with diet
restriction and loss of wt. Less change in
diastolic pressure
75% of the hypertensives showed a fall of B.P.
to normal of less than 135 mm Hg with
weight reduction. Weight reduction has no
effect on obese individuals with severe
hypertension
For 38 obese hypertensives with systolic over
150 mm Hg, mean weight loss was 32 pounds
over 6.4 months, mean systolic pressure drop
was 32 mm Hg. For 30 obese females out of
the 38 with diastolic over 100 mm Hg as well,
mean wt. loss over 6.5 months was 33 lbs., and
Circulatson, Volume XXXIX, Marcb 1969
 OVERWEIGHT AND HYPERTENSION
Table 3 (continued)
Effect of Weight Reduction on Blood Pressure
Senior
author Study group
age 54.9 years. 21 obese
hypertensive females who
failed to lose weight and 20
obese normotensive females
were used for control
Dahl 12 obese hypertensive
1958 patients 20-100% overweight
(84) having hypertension for 2-14 Group 2: Low-salt, no calorie restriction all
years. Low-salt diet with
85-105 mg Na/daily, and low
calorie 600-800 calorie/daify.
The low-salt diet and low-
calorie diet were alternated to
make a single change at a
time, calorie or salt
Salzano 16 normotensive obese
1958 persons,12 females, 4 male
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(80) with 14-85% overweight.
Weight reduction 2 lbs/wk
Olson 83 normotensives and 38
1959 hypertensive subjects
(91)
Adlersberg 54 obese hypertensive
1946 patients on 1,200 calorie diet,
(83) no drug or dehydration,
seen 1940-1941, 15 patients
re-examined 1944
Keys Minnesota Experiment
1947 34 healthy men on 1,600
(77) calorie diet for 6 months,
(control wt. 69.4 kg)
Green 1,260 obese patients.
1948 149 (11.8% hypertensive)
(48) age 30-60
Brozek Observations on European
1948 countries: Russia (Leningrad), 2. Hypertensive complications decreased;
(76) Holland and Germany during
World War II with drastic
food shortage
Circulation, Volume XXXIX, March 1969
413
Results
diastolic pressure drop was 16.5 mm Hg. No
significant B.P. changes observed in the
control group of 21 obese hypertensives and
20 obese normotensive females. A group of
obese normotensive females who lost weight
also showed B.P. drop
Group 1: Low-calorie, no salt restriction only
one out of four with B.P. reduction
four patients showed a significant
B.P. drop more than usual
experience. Obese hypertensive
seems more sensitive to salt
restriction
Group 3: Low-calorie diet at first and low-
salt diet added later: Only one out
of four with B.P. reduction with
low calorie diet alone at first; when
low salt diet was added, all four
showed significant reduction of blood
pressure
Average systolic and diastolic pressure
reductions were 12/8 mm Hg respectively;
81% showed significant systolic pressure
reduction, 65% showed significant diastolic
pressure reduction
No reduction of blood pressure in normoten-
sive group with a weight loss of 14 lbs. over 4-8
months period; 75% of hypertensive group
showed significant reduction of blood pressure
after weight reduction
Average weight loss was 23 2 lbs.; 72% with
significant B.P. drop; 28% with no change of
B.P. Those who maintained low weight had
favorable prognosis. Wt. reduction had no
effect on retinopathy
Mean B.P. drop 106/69 to 97/64 mm Hg.
Mean pulse rate 56 to 37 per minute
Mean V02 reduction 228 to 145 ml/min
Heart size also reduced
Weight reduction brought i of the obese
hypertensives to normal B.P. Influence of
weight reduction on B.P. is inconsistent
1. Incidence of hypertension decreased
clinical severity reduced
3. Autopsy findings of hypertensive disease
decreased
4. Hypotension common among prisoners of
war
 414
Kempner High carbohydrate diet, low
1949 salt and high potassium
(85)
Wilhelmj Animal experiment. 4 normal 1. B.P. change during fasting period:
1951 dogs with 13 fasting periods.
(75) Mean wt. loss 4 kg
(16-12 kg)
Martin 37 middle-aged obese patients 13 of 18 normotensives showed no change of
1952 wt. 212-218 lbs; 18 hyper-
(79) tensive, 19 normotensive;
Average wt. loss 42 lbs., for showed no change of B.P., 2 with both
normotensive, and 36 lbs. for systolic and diastolic pressure drop, 5 with
hypertensives
* Date of publication
followed up from 1954 to 1957, the incidence
rate of hypertension and hypertensive cardio-
vascular disease was twice as high in the over-
weight group.72 Kannel and his associates27
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reported on the development of hypertension
in the Framingham study. Of 5,127 men and
women aged 30 to 62 years at the initial
examination and followed for more than 12
years, subsequent development of hyperten-
sion was related not only to gross obesity but
to relative weight, as determined on the initial
examination. Thus, the risk of developing
hypertension in the group 20% overweight
was eight times greater than in the group 10%
underweight, and the risk of developing
hypertensive cardiovascular disease was about
10 times greater in the group 20% overweight
as compared to all others.27 Men at desirable
weight as young adults who reported little or
no weight gain over a 20-year period had one
fifth the incidence of hypertension (' 150/90)
as compared to those who had a significant
gain of weight in the same period. In the
Framingham study, after a 12 year follow-up
period, the incidence of hypertension (' 160/
95) was also shown to be significantly higher
in persons who gained weight after their
twenty fifth birthday. While 8% of those who
CHIANG ET AL.
Reduction of blood pressure with this diet,
probably due to low salt content as well as
weight reduction
dog 1: 127/62 to 86/35 mm Hg
dog 2: 112/66 to 86/51 mm Hg
dog 3: 102/60 to 74/45 mm Hg
dog 4: 111/43 to 82/37 mm Hg
2. Associated with slowing of heart rate
3. The fall of B.P. to stable state is influenced
by preceding nutritional state, longer to
achieve stable B.P. if previous diet is
luxturious, shorter if previous diet is poor
B.P., 4 with systolic and/or diastolic pressure
drop, one with B.P. rise; 12 of 19 hypertensives
systolic fall alone
had gained from 4 to 15 pounds were hyper-
tensive, almost 20% of the group gaining more
than 29 pounds were hypertensive. The 12-year
incidence of hypertension could be related to
both obesity and to initial relative weight. It
was also noted that the initially obese but
otherwise normal subjects developed diabetes,
cerebrovascular disease, and coronary heart
disease more often.1 2, 73
In summary, with few exceptions, increase
of relative weight over time is associated
with a rise of blood pressure in population
studies. Obese hypertensive patients expenence
a greater risk of coronary heart disease, cere-
brovascular disease and mortality than persons
with either hypertension or obesity alone. The
risk of subsequent development of sustained
hypertension in young adults with obesity or
those becoming obese in the ensuing decades
is greater than among young adults with nor-
mal or less than normal weight who remain
lean.
Effect of Weight Reduction
on Blood Pressure
Experimental and clinical observations on
the effect of weight reduction in 19 studies are
summarized in chronological sequence in
table 3. Animal experiments in normal and
Circulation, Volume XXXIX, March 1969
 OVERWEIGHT AND HYPERTENSION
hypertensive dogs have shown that weight
reduction by fasting is followed by a fall in
both systolic and diastolic pressure and slow-
ing of heart rate.74 When the animals regained
weight by feeding a rich diet, the blood
pressure and heart rate returned to previous
levels. The preceding nutritional state of the
animal is related to the degree of blood pres-
sure fluctuation during weight reduction and
duration of achieving stable low pressure
level.74 75 The animals' systolic blood pres-
sure is affected more markedly than diastolic
pressure.
During a period of drastic food shortage
in World War II, it was observed that the
frequency of hypertension and hypertensive
cardiovascular complications was markedly re-
duced in Russia, Holland, and Germany during
the war and reversed thereafter.76 In one
human experiment, 34 healthy men were on a
low-calorie diet for 6 months and lost about a
quarter of their control body weight; there
was marked reduction of blood pressure, heart
rate, oxygen consumption, and decrease of
cardiac size with reversal when normal weight
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was regained.77
Clinical studies on obese hypertensive pa-
tients have demonstrated a general but vari-
able and inconsistent fall of blood pressure
with weight reduction.78 91 It is more con-
sistent for systolic blood pressure,7 80 in obese
woman,81 with mild to moderate hyperten-
sion,82 substantial and prolonged weight
loss,82 and in combination with salt restric-
tion.84 Prolonged weight reduction in some
obese hypertensive patients was said to have
a favorable effect on the course of the dis-
ease.83 In one study, 38 hypertensive women
who lost 32.4 pounds on the average showed
an average blood pressure fall of 32.8 mm Hg
systolic and 16.5 mm Hg diastolic; a control
group without any change of weight had no
decrease in blood pressure.8 The effect of
caloric restriction on obese hypertensive pa-
tients is enhanced by low-salt intake.84 85
Dahl and co-workers84 found obese hyper-
tensive patients more sensitive to salt restric-
tion than non-obese hypertensives; they con-
cluded that most low-calorie diets also contain
Circulation, Volume XXXIX, March 1969
415
less sodium chloride, and the pressure-lowering
effect is mainly due to salt restriction.
In summary, in spite of the fact that the
effect of weight reduction varies and difficulty
is encountered in keeping patients on diet,
weight reduction lowers blood pressure in a
considerable proportion of obese hypertensive
patients. It is desirable to prescribe weight
reduction in combination with salt restriction
as part of a therapeutic regimen for obese
hypertensive patients.
Overweight and Hypertension: Common
Mechanisms and Pathophysiological Changes
The mechanism of the frequent coexistence
of overweight and hypertension is unknown.
Possible mechanisms and influencing factors
are summarized in table 4. Alexander and
associates,37 38 studying a series of 40 ex-
tremely obese persons with average body
weight of 300 pounds, showed that the hyper-
tensive individuals in this series had increased
cardiac output and normal peripheral resis-
tance. They postulated that an increased
stroke volume is required to pump blood
through an expanded vascular bed in the obese
individual. Blood volume, oxygen consump-
tion, and the transverse diameter of the heart
Table 4
Overweight and Hypertension: Summary of Possible
M[echanisms and Influencing Factors
I. Hemodynamic:
1) Increased V02 and A-V 02 difference, more so
during exercise3 8,9 2,9 3
2) Increased cardiac output with normal peripheral
resistance 21, 2 2, 3 8
3) Increased blood volume and plasma volume 38
II. Hormonal:
1) Increased adrenocortical function 9 7, 9 8
2) Imbalance of renin-angiotensin-aldosterone sys-
tem 96
III. Environmental:
1) Physical inactivity leading to reduced energy
expenditure and overweight 41,94
2) Overeating and high-salt intake 84
IV. Genetic:
1) Endomorph body type 28, 29, 33,43,4 4465
,
2) Family history of obesity and hypertension 3 5, 3 6
 416
also were noted to increase with body
weight.37 38 Proger and Dennig92 found in-
creased oxygen consumption in four moderate-
ly obese patients, but there was no significant
difference in cardiac output and A-V oxygen
difference,as compared to the controls. Taylor
and his colleagues,93 in a study of healthy
adults, found basal cardiac output related to
body weight (r = 0.54); and A-V oxygen dif-
ference positively correlated to body fat
(r = 0.63). Whyte21' 22 has suggested that
high blood pressure in the obese is a result of
increased cardiac output, which is forced into
a reservoir (comprising the aorta and large
arteries), which does not increase with body
weight. In individuals with diseased inelastic
aortae, the effect of increased cardiac output
on blood pressure would be disproportionate-
ly greater. Fletcher81 suggested that the higher
blood pressure in obese persons may be a
physiological response to the greater metabolic
burden and mechanical handicap imposed by
obesity. These suggestions indicate that the
mechanism of the hypertension related to
obesity may be different from essential hyper-
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tension in which cardiac output is normal and
peripheral resistance increased.
Morris and Crawford,94 in a national
necropsy survey of 5,000 cases, noted that
hypertensive heart disease was present in
light workers five times more frequently than
in heavy workers; obese individuals tend to
be more inactive physically. Tibblin41 has
suggested that hypertension and obesity may
be the result of a third set of antecedent
events, such as physical activity. Hartroft,95
in a comparative autopsy series, found renal
weight in obese hypertensive persons to be
normal, but significantly reduced in the whole
series of hypertensive individuals. Obese per-
sons consume not only food above energy
requirement but may also ingest more salt.
According to Dahl and associates,84 blood
pressure levels of obese persons are especially
sensitive to dietary salt restriction. Conn96
suggested that the common triad of obesity,
hypertension, and impairment of carbohy-
drate tolerance in middle aged men may be
related to a form of primary aldosteronism
CHIANG ET AL.
that activates the renin-angiotensin-aldoste-
rone system.
Mild degrees of hypoxia and increased A-V
oxygen difference associated with obesity lead
to increased red-cell mass and increased
blood volume. Another common finding in
obesity is increased corticosteroid secre-
tion.97 98 In pharmacological doses, cortico-
steroids increase cardiac output.99 It is not
clear whether the modest increase in 17-
hydroxysteroid and 17-ketosteroid secretion
in obesity could explain vascular hypertension
or whether the increase in steroid production
is a response to increased circulating blood
volume.'00
Regardless of the underlying pathophysio-
logical mechanism, the hemodynamic and
metabolic changes in obesity may exert an
adverse effect on hypertension. The increased
cardiac output and blood volume in obesity,
when imposed upon persons with hyperten-
sion, may further strain the circulatory system
and compromise its functional adequacy. These
adverse effects are diagramatically illustrated
in figure 1, which illustrates the various patho-
physiological mechanisms that obesity may
add to hypertension. Weight reduction in the
obese hypertensive may remove the extra
metabolic and hemodynamic burdens that
V02 = oxygen consumption
C.O. cardiac output
B.P. ablood pressure
V.R. peripherol vosculor resistonce
L.Vw. left ventriculor worklood
(V=volume lood, P pressure load)
Figure 1
A suggested mechanism for the adverse hemodynaric
effect of obesity in hypertensive subjects.
Circulation, Volume XXXIX, March 1969
 OVERWEIGHT AND HYPERTENSION
obesity imposes upon hypertension. It seems
plausible that weight reduction would dimin-
ish circulatory strain, thus preventing acceler-
ated decompensation in hypertensive heart
disease among the obese, especially when
coupled with appropriate antihypertensive
therapy.
Prognosis of Overweight and Hypertension
The Build and Blood Pressure Study in
19594 showed excessive mortality in overweight
persons among all age and blood pressure
groups. When mortality is assessed by height
and weight levels for three blood pressure
groups (normal, moderate, and more severely
elevated) and three age groups ( 15 to 39,
40 to 49, 50 to 69 at policy issue), the excess
mortality is greatest in the younger age group,
due primarily to cardiovascular disease. Even
slight and moderate overweight is associated
with excess of mortality in the more severely
hypertensive group. According to Lew,101 at
levels of systolic blood pressure of 140 to 160
mm Hg and diastolic pressure of 90 to 100
mm Hg, overweight curtails the expectation of
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life among individuals who are both over-
weight and hypertensive as compared to
hypertensive subjects who are not overweight.
However, longevity is much less affected
among women than men at corresponding
degrees of overweight and hypertension.
Overweight and hypertension are also as-
sociated with an excess of coronary heart
disease and cerebrovascular disease, especially
among men.1' 2, 7 Levy and his colleagues69-71
showed that retirement from active service
and death from cardiovascular renal disease
were more common among Army officers in
the obese-hypertensive group than in the
obese or hypertensive groups alone. Severity
of hypertensive retinopathy and cardiovascu-
lar complications were related to obesity in
Tibblin's study of hypertensive disease in men
aged 50.41 However, in other clinical series of
patients with more severe hypertensive disease,
Bechgaard,'12 Frant,'13 and Mathisen104 found
mortality in obese hypertensive subjects no
higher than in nonobese hypertensive persons.
In fact, obese hypertensive women may have a
Circulation, Volume XXXIX, March 1969
417
relatively better chance of long-term survival.
In a 10-year follow-up study of a small
number of hypertensive patients without
retinal change or only arteriolar narrowing
at the Mayo Clinic, Breslin and colleagues105
showed a slightly greater mortality in in-
dividuals 30% overweight but in individuals
with sclerosis and exudates, the prognosis was
slightly better in the obese group.
Clinical studies are highly selective. The
difference between these studies and the life
insurance company experience may be due to
the fact that the actuarial study dealt with
blood pressures in the range from 140 to 160/
90 to 100 mm Hg, whereas blood pressures in
the clinical investigations were higher. Blood
pressures over 160j100 mm Hg apparently
overshadow the effect of overweight on mor-
tality and the course of severe hypertensive
disease may be altered but little by weight
reduction.83 92 However, in individuals with
a moderate degree of blood pressure elevation
associated with overweight, weight reduction
may significantly change the course of the
disease. Obese persons who are able to reduce
their weight comprise a relatively small and
selected proportion of the total group. Never-
theless, data from the Build and Blood Pres-
sure Study4 indicate a lowering of the mor-
tality ratio among such men; there were too
few women in the series for analysis. Among
those called "moderately obese" (averaging
25% overweight), the mortality ratio was 109%
in those who lost weight, as compared with
a ratio of 128% in the total group; the cor-
responding figures in the "markedly obese"
(averaging 35 to 40% overweight) were 96%
and 151%, respectively.
It is difficult to extrapolate these findings
to what might be the effect of weight reduc-
tion in the population at large. For this reason,
there is a great need for documenting the
potential benefits of weight loss among the
obese and obese hypertensive subjects by
means of further study. However, the con-
verging evidence from a large variety of sources
summarized in this review strongly suggests
that the impact of weight reduction in the
general population would be very considerable
 418
and lessen appreciably the burden of mortality
and also morbidity from cardiovascular dis-
eases.
References
1. STAMLER, J.: Lectures on Preventive Cardi-
ology. New York, Grune & Stratton, Inc.,
1967, p. 256.
2. KANNEL, W. B., LEBAUER, E. J., DAWBER,
T. R., AND MACNAMARA, P. M.: Relation
of body weight to development of coronary
heart disease: Framingham study. Cir-
culation 35: 734, 1967.
3. METROPOLITAN LIFE INSURANCE Co., New
York. Frequency of Overweight and Under-
weight. Stat Bull 41: 4, 1960.
4. BUILD AND BLOOD PRESSURE STUDY, 1959.
Society of Actuaries, Chicago, Vols. 1 and 2,
1959.
5. WHITE, P. L.: The nutritionist. JAMA 186:
34, 1963.
6. NATIONAL CENTER FOR HEALTH STATISTICS.
Weight, Height, and Selected Body Dimen-
sions of Adults. Public Health Service, U. S.
Dept. of Health, Education and Welfare,
Washington, D. C., 1965, Series 11, No. 8.
7. NATIONAL CENTER FOR HEALTH STATISTICS:
Weight by Height and Age of Adults,
United States, 1960-1962. Public Health
Downloaded from http://ahajournals.org by on October 25, 2022
Service. U. S. Dept. of Health, Education,
and Welfare. Washington, D. C., 1965,
Series 11, No. 14.
8. HEALD, F. P., HUNT, E. D., JR., SCHWARTZ,
R., COOK, C. D., ELLIOT, O., AND VAJDA,
B.: Measures of body fat and hydration in
adolescent boys. Pediatrics 31: 226, 1963.
9. NOVAK, L. P.: Age and sex differences in body
density and creatinine excretion of high
school children. Ann N Y Acad Sci 110:
545, 1963.
10. BROZEK, J., AND KEYS, A.: Evaluation of
leanness, fatness in man: Norms and in-
terrelationships. Brit J Nutr 5: 194, 1951.
11. PASCALE, L. R., GROSSMAN, M. I., SLOANE,
H. S., AND FRANKEL, T.: Correlations be-
tween thickness of skinfolds and body densi-
ty in 88 soldiers. Hum Biol 28: 165, 1956.
12. EDELMAN, I. S.: Body Water and Electrolytes
in Techniques for Measuring Body Composi-
tion. Edited by J. Brozek and A. Henschel,
Washington, D. C., National Academy of
Sciences, 1961, p. 155.
13. FORBES, G. B., GALLUP, J., AND HURSH, F. B.:
Estimation of total body fat from potassium-
40 content. Science 133: 101, 1961.
14. COMMITTEE ON NUTRITIONAL ANTHROPOMETRY,
FOOD AND NUTRITION BoARD, NATIONAL
RESEARCH COUNCIL. A. Keys, Chairman. Rec-
CHIANG ET AL.
ommendations Concerning Body Measure-
ments for the Characterization of Nutritional
Status in Body Measurements for Human
Nutrition. Edited by J. Brozek, Detroit,
Wayne University Press, 1956, p. 10.
15. STUART, H. C., HILL, P., AND SHAW, C.: The
Growth of Bone, Muscle and Overlying Tis-
sues as Revealed by Studies of Roentgeno-
grams of the Leg Area (monograph). Evans-
ton, Ill., Society for Research in Childhood
Development, Inc. 1949, Vol. 5, No. 3, Serial
No. 26.
16. SELTZER, C. C., AND MAYER, J.: Simple Crite-
rion of obesity. Postgrad Med 38: Al1l,
1965.
17. MAYER, J.: Some aspects of the problem of
regulation of food intake and obesity. New
Eng J Med 274: 610, 1966.
18. HYPERTENSION AND CORONARY HEART DIS-
EASE: Classification and Criteria for Epi-
demiological Studies, WHO Technical Report
Series No. 168, 1959.
19. TECUMSEH COMMUNITY HEALTH STUDY: Un-
published data.
20. EPSTEIN, F. H., AND ECKHOFF, R. D.: Epi-
demiology of high blood pressure-geographic
distributions and etiological factors, In The
Epidemiology of Hypertension. Edited by
J. Stamler, R. Stamler, and T. N. Pullman.
New York, Grune & Stratton, pp. 155-166.
21. WHYTE, H. M.: Behind the adipose curtain.
Amer J Cardiol 15: 66, 1965.
22. WHYTE, H. M.: Blood pressure and obesity.
Circulation 19: 511, 1959.
23. SHAPER, A. G.: Blood pressure studies in East
Africa. In The Epidemiology of Hypertension.
Edited by J. Stamler, R. Stamler, and
T. N. Pullman. New York, Grune & Stratton,
1967, pp. 139-145.
24. KEYS, A., ET AL.: Epidemiological studies related
to coronary heart disease: Characteristics of
men age 40-59 in seven countries. Acta Med
Scand (suppl. 460), 1967.
25. PALMAI, G.: Skin fold thickness in relation to
body weight and arterial blood pressure. Med
J Aust 49: 13, 1962.
26. EPSTEIN, F. H., ET AL.: Prevalence of chronic dis-
ease and distribution of selected physiological
variables in a total community, Tecumseh,
Michigan. Amer J Epidem 81: 307, 1965.
27. KANNEL, W. B., BRAND, N., SKINNER, J. J.,
DAWBER, T. R., AND MCNAMARA, P. M.: Re-
lation of adiposity to blood pressure and de-
velopment of hypertension: The Framingham
study. Ann Intern Med 67: 48, 1967.
28. BJERKEDAL, T.: Overweight and hypertension.
Acta Med Scand 159: 13, 1957.
29. BOE, J., HUMERFELT, S., AND WEDERvANG, G.:
Blood pressure in a population: Blood pres-
Circulation, Volume XXXIX, March 1969
 OVERWEIGHT AND HYPERTENSION
sure readings and height and weight deter-
minations in the adult population of the
City of Bergen. Acta Med Scand (suppl.
321), 1957.
30. BOYLE, E., JR., GRIFFEY, W. P., NICHAMAN, M.
Z., AND TALBERT, C. R., JR.: Epidemiological
study of hypertension among racial groups in
Charleston County, South Carolina. The
Charleston Heart Study, Phase II, In The
Epidemiology of Hypertension. Edited by J.
Stamler, R. Stamler, and T. N. Pullman.
New York, Grune & Stratton, 1967, pp. 193-
203.
31. McDONOUGH, J. R., GARRISON, G. E., AND
HAMES, C. G.: Blood pressure and hyper-
tensive disease among Negroes and whites
in Evans County, Georgia. In The Epidemiol-
ogy of Hypertension. Edited by J. Stamler,
R. Stamler, and T. N. Pullman. New York,
Grune & Stratton, 1967, pp. 167-187.
32. MIALL, W. E., BELL, R. A., AND LOVELL, H. G.:
Relation between change in blood pressure
and weight. Brit J Prev Soc Med 22: 73,
1968.
33. ROBINSON, S. C., BRUCER, M., AND MASS, J.:
Hypertension and obesity. J Lab Clin Med
25: 807, 1939.
34. TRUEDSSON, E.: Variation of arterial blood pres-
sure and serum cholesterol levels in coconut-
eating Polynesians. Fed Proc (suppl 11) 21:
Downloaded from http://ahajournals.org by on October 25, 2022
36, 1962.
35. BOYNTON, R. E., AND TODD, R. L.: Relation of
body weight and family history of hyperten-
sive disease to blood pressure levels in uni-
versity students. Amer J Med Sci 216: 397,
1948.
36. THOMAS, C. B., AND COHEN, B. H.: Familial
occurrence of hypertension and coronary
artery disease; with observations concerning
obesity and diabetes. Ann Intern Med 42: 90,
1955.
37. ALEXANDER, J. K., AND DENNIS, E. W.: Cir-
culatory dynamics in extreme obesity. Circu-
lation 20: 662, 1959.
38. ALEXANDER, J. K.: Obesity and the circulation.
Mod Conc Cardiovasc Dis 32: 799, 1963.
39. HARTMAN, H. R., AND GHRIST, D. G.: Blood
pressure and weight. Arch Intern Med 44:
877, 1929.
40. REID, D. O., HOLLAND, W. W., HUMERFELT,
S., AND ROSE, G. A.: Cardiovascular survey
of British postal workers. Lancet 1: 614,
1966.
41. TIBBLIN, G.: High blood pressure in men
aged 50. Acta Med Scand (suppl 470), 1967.
42. CHIANG, B. N., TING, N., Li, Y. B., PAO, Y. L.,
ALEXANDER, E. R., BRUCE, R. A., AND GRAY-
STON, J. T.: Maximal exercise responses in
middle aged hypertensive and normotensive
Circulation, Volume XXXIX, March 1969
419
Chinese males; Preliminary report. Chin
Med J 14: 239, 1967.
43. JOHNSON, B. C., AND REMINGTON, R. D.: Sam-
pling study of blood pressure levels in white
and Negro residents of Nassau, Bahamas. J
Chron Dis 13: 39, 1961.
44. LARIMORE, J. W.: Study of blood pressure in
relation to type of body habitus. Arch Intern
Med 31: 567, 1923.
45. MAEuKs, H. H.: Influence of obesity on mor-
bidity and mortality. Bull N Y Acad Med 36:
296, 1960.
46. HUBER, E. G.: Systolic blood pressure of healthy
adults in relation to body weight. JAMA
88: 1554, 1927.
47. SHORT, J. J., AND JOHNSON, H. J.: Evaluation
of the influence of overweight on blood pres-
sure of healihy men. Amer J Med Sci 198:
220, 1939.
48. GREEN, M. B., AND BECKMAN, M.: Obesity and
hypertension. New York J Med 48: 1250,
1948.
49. MASTER, A. M., JAFFE, H. L., AND CHESKY,
K.: Relationship of obesity to coronary dis-
ease and hypertension. JAMA 153: 1499,
1953.
50. PADMAVATI, S., AND GUPTA, S.: Blood pressure
studies in rural and urban groups in Delhi.
Circulation 19: 395, 1959.
51. STAMLER, J., BERKSON, D. M., LINDBERG, H. A.,
MILLER, W., AND HALL, Y.: Racial patterns
of coronary heart disease: Blood pressure,
body weight and serum cholesterol in whites
and Negroes. Geriatrics 16: 382, 1961.
52. NUTRrrION SURVEY OF THE ARMED FORCES; A
Report by Interdepartmental Committee on
Nutrition for National Defense. Washington
25, D. C., U. S. Gov't Printing Office. Thai-
land (1960); Republic of China (1960);
Ethiopia (1959); Philippines (1957); Uru-
guay (1963); Alaska (1959); Chile (1960).
53. DOYLE, A. E., AND LOVELL, R. R. H.: Blood
pressure and body build in men in tropical
and temperate Australia. Clin Sci 20: 243,
1961.
54. ALEKSANDROW, D.: Studies on thc epidemiol-
ogy of hypertension in Poland. In The Epi-
demiology of Hypertension. Edited by J.
Stamler, R. Stamler, and T. N. Pullman.
New York, Grune & Stratton, 1967, pp. 82-
97.
55. HUNTER, J. D.: Diet, body build, blood
pressure and serum cholesterol levels in
coconut-eating Polynesians. Fed Proc (suppl
11) 21: 36, 1962.
56. RAGAN, C., AND BORDLEY, J., JR.: Accuracy of
clinical measurements of arterial blood pres-
sure. Bull Johns Hopkins Hosp 69: 504,
1941.
 420
57. PICKERING, G. W., ROBERTS, J. A. F., AND SOW-
RY, G. S. C.: Etiology of essential hyperten-
sion: Effect of correcting for arm circumfer-
ence on the growth rate of arterial pressure
with age. Clin Sci 13: 267, 1954.
58. MIALL, W. E., AND OLDHAM, P. D.: Study of
arterial blood pressure and its inheritance in
a sample of the general population. Clin Sci
14: 459, 1955.
59. RAFTERY, E. B., AND WARD, A. P.: Indirect
method of recording blood pressure. Cardio-
vasc Res 2: 210, 1968.
60. HOLLAND, W. W., AND HUMERFELT, S.: Mea-
surement of blood pressure: Comparison of
intra-arterial and cuff values. Brit Med J 2:
1241, 1964.
61. BERLINER, K., FUJIY, H., LEE, D. H., YILDIz,
M., AND GARNIER, G.: Blood pressure mea-
surements in obese persons: Comparison of
intra-arterial and auscultatory measurements.
Amer J Cardiol 8: 10, 1961.
62. KARLEFORS, T., NILSEN, R., AND WESTLING,
H.: On the accuracy of indirect auscultatory
blood pressure measurements during exercise.
Acta Med Scand (suppl. 449): 81, 1966.
63. NAGLE, F. J.: Comparisons of direct and in-
direct blood pressure with pressure flow dy-
namics during exercise. J Appl Physiol 21:
317, 1966.
64. KHOSLA, T., AND LowE, C. R.: Arterial pressure
Downloaded from http://ahajournals.org by on October 25, 2022
and arm circumference. Brit J Prev Soc Med
19: 159, 1965.
65. LOWE, C. R.: Arterial pressure, physique and
occupation. Brit J Prev Soc Med 18: 115,
1964.
66. KARVONEN, M. J.: Effect of sphygmomanometer
cuff size on blood pressure measurement, Bull
WHO 27: 805, 1962.
67. KING, G. E.: Errors in clinical measurement of
blood pressure. Clin Sci 32: 223, 1967.
68. ROSE, G. A., HOLLAND, W. W., AND CROWLEY,
E. A.: Sphygmomanometer for epidemiolo-
gists. Lancet 1: 296, 1964.
69. LEVY, R. L., WHITE, P. D., STROUD, W. D., AND
HILLMAN, C. C.: Overweight: Prognostic
significance in relation to hypertension and
cardiovascular-renal diseases. JAMA 131:
951, 1946.
70. LEVY, R. L., WHITE, P. D., STROUD, W. D.,
AND HILLMAN, C. C.: Transient hyperten-
sion: Relative prognostic importance of vari-
ous systolic and diastolic levels. JAMA 128:
1059, 1945.
71. LEVY, R. L., WHITE, P. D., STROUD, W. D., AND
HILLMAN, C. C.: Transient tachycardia:
Prognostic significance alone and in associa-
tion with transient hypertension. JAMA 129:
585, 1945.
72. STAMLER, J.: On the natural history and epi-
CHIANG ET AL.
demiology of hypertensive disease. In The
Pathogenesis of Essential Hypertension.
Edited by J. H. Cort, V. Fencl, Z. Hejl,
and E. Jirka. Proc of the Prague Symposium,
Prague, Czechoslovakia: State Medical Pub-
lishing House, 1960, pp. 67, 107.
73. KANNEL, W. B., DAWBER, T. R., AND McNA-
MARA, P. M.: Vascular disease of the brain
-Epidemiologic aspects: Framingham study.
Amer J Pub Health 55: 1355, 1965.
74. WOOD, J. E., AND CASH, J. R.: Obesity and
hypertension: Clinical and experimental ob-
servations. Ann Intern Med 13: 81, 1939.
75. WILHELMJ, C. M., WLADMANN, E. B., AND
MCGUmE, T. F.: Basal blood pressure of nor-
mal dogs determined by an auscultatory
method and a study of the effect of fasting.
Amer J Physiol 166: 296, 1951.
76. BROZEK, J., CHAPMAN, C. B., AND KEYS, A.:
Drastic food restriction: Effect on cardiovas-
cular dynamics in normotensive and hyper-
tensive conditions. JAMA 137: 1569, 1948.
77. KEYS, A., HENSCHEL, A., AND TAYLOR, H.: Size
and function of human heart at rest in semi-
starvation and in subsequent rehabilitation.
Amer J Physiol 150: 153, 1947.
78. MASTER, A. M., AND OPPENHEIMER, A.: Study
of obesity: Circulatory, roentgen-ray and elec-
trocardiographic investigations. JAMA 92:
1652, 1929.
79. MARTIN, L.: Effect of weight reduction on nor-
mal and raised blood pressure in obesity.
Lancet 2: 1051, 1952.
80. SALZANO, J. V., GUNNING, R. V., MASTOPAULO,
T. N., AND TUTTLE, W. W.: Effect of weight
loss on blood pressure. J Amer Diet Ass 34:
1309, 1958.
81. FLETCHER, A. P.: Effect of weight reduction
upon blood pressure of obese hypertensive
women. Quart J Med 23: 331, 1954.
82. EVANS, F. A., AND STRANG, J. M.. Treatment
of obesity with low calorie diet. JAMA
97: 1063, 1931.
83. ADLERSBERG, D., COLCHER, H. R., AND LAVAL,
J.: Effect of weight reduction on course of
arterial hypertension. J Mount Sinai Hosp
N Y 12: 984, 1946.
84. DAHL, L. K., SILVER, L., AND CHRISTIE, R. W.:
Role of salt in the fall of blood pressure ac-
companying reduction of obesity. New Eng
J Med 258: 1186, 1958.
85. KEMPNER, W.: Treatment of heart and kidney
disease and of hypertensive and arterio-
sclerotic vascular disease with rice diet. Ann
Intern Med 31: 821, 1949.
86. BENEDICT, F. G., AND ROTH, P.: Effect of a pro-
longed reduction in diet on twenty-five men.
Proc Nat Acad Sci 4: 149, 1918.
Circulation, Volume XXXIX, March 1969
 OVERWEIGHT AND HYPERTENSION
87. PRBLE, W. E.: Obesity: Observations on one
thousand cases. Boston Med Surg J 188:
617, 1923.
88. TERRiY, A. H., Jn.: Obesity and bypertension.
JAMA 81: 1283, 1923.
89. BAU-MAN, L.: Obesity: Recent reports in the
literature and results of treatment. JAMA 90:
22, 1928.
90. FELLOWS H. A.: Studies of relatively normal
obese individuals during and after dietary
restrictions. Amer J Med Sci 181: 301, 1931.
91. OLSON, R. E.: Obesity as a nutritional disorder.
Fed Proc 18: (Part I) 58, 1959.
92. PROGER, S. H., AND DENNIG, H.: Study of the
circulation in obesity. J Clin Invest 11: 789,
1932.
93. TAYLOR, H. L., BROZEK, J., AND KEYS, A.: Basal
cardiac function and body composition with
special reference to obesity. J Clin Invest 31:
976, 1952.
94. Moiuiuis, J. N., AND CRAWFORD, M. D.: Coronary
heart disease and physical activity of work:
Evidence of a national necropsy survev. Brit
Med J 2: 1485, 1958.
95. HARTROFT, W. S.: Pathology of obesity. Bull
N Y Acad Med 36: 313, 1960.
96. CoNN, J. W.: Hypertension, the potassium ion
and impaired carbohydrate tolerance. New
Eng J Med 273: 1135, 1965.
97. SCHTEINTGART, D. E.: Characteristics of in-
Downloaded from http://ahajournals.org by on October 25, 2022
creased adrenocortical function observed in
many obese persons. Ann N Y Acad Sci 131:
388, 1965.
Ctrcula;ion, Volume XXXIX, March 1969
421
98. SCHTEINGART, D. E., GCrEGEWMAN, R. I., AND
CONyT, J. W.: Comparison of the characteris-
tics of increased adrenocortical function in
obesity and Cushing's syndrome. Metabolism
12: 484, 1963.
99. SANlBIl, MN. P., WEIL, M. H., AND UDHOJI,
V. M.: Acute pharmaeodynamic effects of
glucocorticoids: Cardiac output and related
hemnodynamic changes in norn1al subjects and
patients in shock. Circulation 31: 523, 1965.
100. EImLICir, EDWARD: Aldosterone, the adrenal
cortex and hypertension. Ann Rev Med 19:
373, 1968.
101. LEXS, E. A.: Blood pressure and mortality-
Life insurance experience. In The Epidemiol-
ogy of Hypertension. Edited by J. Stamiler, R.
Stamler, and T. N. Pullman. New York, Grune
and Stratton, 1967, pp. 392-397.
102. BECIIGAARD, P.: Natural historv of benign hy-
pertension. In Essential Hypertension: An In-
ternational Symposium. Edited by F. C.
Reubi, K. D. Bock, and P. T. Cattier. Berlin,
Springer-Verlag, 1960, p. 198.
103. FLIANT, F., AND GCROEN, J.: Prognosis of vascular
hypertension: Nine-year follow-up study of
four hundred and eighteen cases. Arch Intern
MIed 85: 727, 1950.
104. MATHISEN, H. S., JENSEN, D., LOKEN, E., AND
LOKEN, H.: Prognosis of essential hyperten-
sion. Amer Heart J 57: 371, 1959.
105. BRESLIN, D. J., GIFFORD, R. W., JR., AND FAIR-
1BAIRNES, J. F., II: Essential hypertension:
A twenty year follow-up study. Circulation
33: 87, 1966.