Weight-Loss Efforts in US Adults with Hypertension and Overweight or Obesity

Although weight-loss attempts among US adults with hypertension and overweight or obesity increased significantly between 1999 and 2023, the rate of achieving clinically meaningful weight loss remained stagnant, revealing a persistent gap between effort and outcome.

The Gist

The Big Picture: Trying Harder, But Not Getting There

Imagine a massive gym in the United States called "Hypertension High School." The students here all have high blood pressure and are carrying extra weight. For the last 25 years, researchers have been watching these students to see if they are trying to get in shape and, more importantly, if they are actually succeeding.

The study, which looked at data from 1999 to 2023, found a frustrating but important truth: More students are showing up to the gym and trying harder, but the number of students actually losing the weight hasn't improved.

The Story in Three Acts

Act 1: The Effort is Up (The "Sign-Up Sheet" is Full)

In the early 2000s, about 56% of these students said, "I'm going to try to lose weight this year." By 2023, that number went up to about 60%.

• The Analogy: It's like a New Year's resolution. More people are signing up for the diet plan, buying the gym memberships, and promising to change. Everyone is more aware that they need to lose weight to control their blood pressure.
• Who is trying? Women, people with higher education, and people with obesity are trying the hardest. Interestingly, low-income groups have also started trying much more often in recent years, likely because community programs are reaching them better.

Act 2: The Results are Stuck (The "Scale" Won't Budge)

Here is the bad news. Even though more people are trying, the number of people who actually lose a clinically meaningful amount of weight (5% to 10% of their body weight) has stayed exactly the same for 25 years.

• The Analogy: Imagine a group of hikers trying to climb a steep mountain. In 1999, 30% of the hikers made it to the halfway point. In 2023, even though more hikers started the climb, only 30% still made it to the halfway point. The mountain didn't get easier, and the hikers didn't get better gear; they just started walking more often.
• The Gap: There is a huge gap between intention (wanting to lose weight) and outcome (actually losing it).

Act 3: What Strategies Work? (The "Secret Weapons")

The researchers asked the students, "What did you do to try to lose weight?"

• The Most Common Moves: "Eat less food" and "Exercise more." These are the classic, go-to strategies. They are like trying to fix a leaky roof with a bucket. It helps a little, but it's not a permanent fix.
• The Surprising Winners: The people who actually succeeded were more likely to say they "changed their eating habits" (like cooking differently or changing what they eat) rather than just "eating less."
• The Heavy Hitters: The most effective tools were weight-loss surgery and prescription medications. However, almost no one used them (less than 1% used surgery, and only about 2.6% used meds).
  • The Analogy: It's like trying to put out a forest fire with a water pistol (dieting) when you have a fire truck (meds/surgery) parked right next to you, but nobody is allowed to drive it because it's too expensive or hard to get.
• The Traps: Some strategies actually made things worse. Skipping meals and using diet pills were linked to less success. Also, while smoking was linked to weight loss, the authors warn this is a trap—smoking hurts the heart and raises blood pressure, which is the exact opposite of what these patients need.

Why Is This Happening?

The paper suggests a few reasons why the "effort" isn't turning into "success":

1. The "Obesogenic" Environment: It's like trying to diet while walking through a candy store that never closes. Even if you try to eat less, the world is full of cheap, unhealthy food and places where it's hard to exercise safely.
2. The "One-and-Done" Approach: Many people try to lose weight on their own, without a coach or a long-term plan. Once they slip up, they quit. Weight management needs to be treated like a chronic disease (like diabetes), requiring constant care, not a one-time fix.
3. The "Overweight" vs. "Obesity" Gap: People with severe obesity seem to get more help from doctors (more referrals to specialists) than people who are just "overweight." The people with mild excess weight often get told to "just eat less," which isn't enough to break the cycle.

The Takeaway: What Needs to Change?

The authors conclude that we can't just keep telling people to "try harder." The willpower is there; the system is broken.

To fix this, we need to treat weight loss in people with high blood pressure like a serious medical treatment:

• Team Approach: Doctors shouldn't work alone. We need dietitians, coaches, and pharmacists working together.
• Better Tools: We need to make sure people can actually afford and access the "heavy hitters" (modern medications and surgery) that work.
• Long-Term Care: Instead of a 3-month diet plan, patients need a lifelong support system with regular check-ins, just like they do for their blood pressure medication.

In short: Americans with high blood pressure are finally waking up and trying to lose weight. But without better tools, better support, and a system that treats obesity as a serious medical condition, they are running in place.

Technical Summary

1. Problem Statement

The concurrent epidemics of obesity and hypertension in the United States present a critical public health challenge. Excess adiposity is a primary driver of hypertension, leading to difficult blood pressure control and increased cardiometabolic risk. While clinical guidelines (e.g., AHA/ACC 2025) strongly recommend weight management as a foundational strategy for hypertension care, there is a lack of national data regarding:

• The prevalence and temporal trends of weight-loss attempts specifically among adults with hypertension and overweight/obesity.
• Whether these efforts translate into clinically meaningful weight loss (defined as ≥5% or ≥10% reduction) at the population level.
• The effectiveness of specific self-reported strategies in achieving these outcomes over the last two decades.

2. Methodology

Study Design & Data Source:

• Type: Repeated cross-sectional analysis.
• Data Source: National Health and Nutrition Examination Survey (NHANES), 1999–2023.
• Sample: 17,383 US adults (aged ≥20) with hypertension and BMI ≥25 kg/m².
  • Exclusions: Pregnant individuals, those without hypertension, missing BMI/weight data, or missing covariates.
• Survey Cycles: Pooled data from 12 consecutive 2-year cycles (1999–2023).

Key Definitions:

• Hypertension: Systolic BP ≥140 mmHg, Diastolic BP ≥90 mmHg, self-reported diagnosis, or use of antihypertensive medication.
• Weight-Loss Attempt: Self-reported affirmative response to "tried to lose weight during the past 12 months."
• Success Metrics:
  • ≥5% Weight Loss: Clinically meaningful threshold.
  • ≥10% Weight Loss: Higher threshold for significant clinical impact.
  • Calculation: Based on self-reported current weight vs. weight 1 year prior.
• Strategies: 14+ self-reported strategies (e.g., eating less, exercise, diet pills, surgery). Note: Strategy data was restricted to 1999–2020 as 2021–2023 cycles lacked these specific items.

Statistical Analysis:

• Weights: Survey-weighted analyses accounting for NHANES complex multistage sampling design.
• Trend Analysis: Linear and logistic regression models adjusted for age, sex, race/ethnicity, education, income, and BMI category.
• Association Analysis: Multivariable logistic regression (Model 1: all strategies; Model 2: backward stepwise selection) to identify strategies associated with successful weight loss (ORs with 95% CIs).

3. Key Contributions

• Population-Specific Focus: Unlike previous studies focusing on the general US population, this study isolates adults with hypertension, a high-risk group where weight loss is directly linked to blood pressure control.
• Longitudinal Trend Analysis: Provides a 24-year perspective (1999–2023) on the gap between weight-loss intent and outcome.
• Strategy Effectiveness: Identifies specific behaviors (e.g., changing eating habits vs. skipping meals) that correlate with success or failure, offering actionable insights for clinical counseling.
• Disparity Analysis: Highlights how socioeconomic status and BMI category (overweight vs. obesity) influence both the attempt to lose weight and the success rate.

4. Key Results

A. Weight-Loss Attempts (Trends)

• Overall Increase: The proportion of adults attempting to lose weight rose significantly from 55.9% (1999–2000) to 60.4% (2021–2023) ($P_{trend}=0.002$).
• Demographics: Attempts were higher in women, those with higher education/income, and those with obesity (67.5%) vs. overweight (44.2%).
• Socioeconomic Shift: Notably, the increase in attempts was most pronounced in low-income groups (49.5% to 63.1%), suggesting improved access to initial motivation or awareness, though not necessarily resources for sustained success.

B. Clinically Meaningful Weight Loss (Outcomes)

• Stagnation: Despite increased attempts, success rates did not improve over time.
  • ≥5% Loss: Remained stable (~33.4% overall; $P_{trend}=0.976$).
  • ≥10% Loss: Remained stable (~14.7% overall; $P_{trend}=0.174$).
• BMI Stratification:
  • Among those with obesity, ≥10% loss increased significantly (12.6% to 22.1%).
  • Among those with overweight, ≥10% loss declined (8.6% to 5.1%).

C. Strategies and Associations

• Most Common Strategies: Eating less food (65.3%) and exercise (52.4%).
• Positive Associations with Success:
  • Weight-loss surgery: Strongest association (OR ~5.4–6.4), though rarely reported (0.35%).
  • Changing eating habits: Positively associated with both ≥5% and ≥10% success.
  • Eating less fat: Positively associated with ≥5% success.
  • "Other" methods & Smoking: Showed high ORs, but smoking is a confounder (appetite suppression) and not a recommended strategy.
• Negative Associations with Success:
  • Skipping meals: Inversely associated with success (OR 0.74 for ≥5%).
  • Diet foods/products: Inversely associated with ≥10% success.
• Temporal Strategy Shifts:
  • Increased: Drinking water, eating more produce, reducing sugar/fast food.
  • Decreased: Eating less fat, choosing low-calorie foods.
  • Stable: Eating less food and exercising.

5. Significance and Implications

The "Intention-Outcome" Gap:
The study reveals a persistent disconnect: while awareness and effort to lose weight have increased (likely due to public health messaging and clinical guidelines), the population-level success rate has not improved. This suggests that "willpower" and general advice (e.g., "eat less, move more") are insufficient without structured support.

Clinical & Policy Implications:

1. Reframing Obesity Care: Weight management for hypertensive patients must be treated as a chronic disease process requiring longitudinal support, not a one-time lifestyle advice session.
2. Need for Escalation: The low utilization of evidence-based interventions (only 0.4% surgery, 2.6% pharmacotherapy) indicates a failure in the "stepped-care" model. Clinicians should escalate to pharmacotherapy and metabolic surgery more readily for non-responders.
3. Targeted Counseling: General advice is less effective than specific behavioral changes (e.g., "changing eating habits" vs. "skipping meals").
4. Equity: While low-income groups are attempting weight loss more, structural barriers (food insecurity, lack of safe exercise spaces) prevent success. Policy must address these social determinants.
5. Future Directions: The emergence of GLP-1 agonists offers promise, but their impact depends on equitable access and integration into comprehensive care models that include behavioral support and follow-up.

Limitations:

• Self-reported data (weight and strategies) subject to recall and social desirability bias.
• Cross-sectional design precludes causal inference.
• Small sample sizes for rare strategies (surgery, smoking) resulted in wide confidence intervals.
• Exclusion of institutionalized populations.