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Editorial
September 9, 2020

Obesity and Hypertension in the Time of COVID-19

Author Affiliations
  • 1National Institutes of Health, Bethesda, Maryland
  • 2National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
JAMA. 2020;324(12):1163-1165. doi:10.1001/jama.2020.16753

In this issue of JAMA, 2 reports1,2 present cross-sectional data on the prevalence and trends for obesity and controlled hypertension from 1999 through 2018 based on data from the National Health and Nutrition Examination Survey, a federal program of nationally representative surveys designed to monitor the health and nutrition of adults and children in the US.3

At first glance, these 2 studies may appear to be addressing different issues. Ogden et al1 describe the seemingly inexorable increase in obesity prevalence among both children and adults, a condition that has few preventive strategies that have proven effective on a population basis despite recognition of its adverse effect on health. Muntner et al2 document a substantial decrease in the successful control of hypertension among US adults, a disease for which effective medical treatments exist. Hypertension increases the risk for heart disease, stroke, and chronic kidney disease, which are 3 leading causes of death for US residents, and effective treatment of hypertension can reduce the risk of these diseases.4 In addition to its contribution to cardiovascular and kidney diseases, obesity increases the risk for diseases affecting almost every organ system, including type 2 diabetes, nonalcoholic fatty liver disease, and certain types of cancer.5 The prevalence of both obesity and uncontrolled hypertension remains disturbingly high. As documented in both studies, these health indicators are moving in the wrong direction in all populations but occur disproportionately in racial and ethnic minority groups.

In the study by Ogden et al,1 the prevalence of childhood obesity (body mass index [BMI; calculated as weight in kilograms divided by height in meters squared] ≥95th percentile for age) increased between 1999-2000 and 2017-2018 among both 6- and 11-year-olds (from 15.8% to 19.3%) and adolescents (from 16.0% to 20.9%), with greater increases in non-Hispanic Black and Mexican American adolescents than in non-Hispanic White adolescents. In addition, severe obesity (defined as BMI ≥120% of the 95th percentile) was more than twice as prevalent in non-Hispanic Black adolescents (13.0%) and Mexican American adolescents (12.9%) than in non-Hispanic White adolescents (4.9%). This is particularly concerning because adolescents with severe obesity are at high risk for the development of serious comorbidities, including type 2 diabetes, which has a more malignant course and is less amenable to therapies than type 2 diabetes acquired later in life.6

Among adults, the prevalence of obesity (BMI ≥30) increased between 1999-2000 and 2017-2018 from 27.5% to 43% for men and from 33.4% to 41.1% for women, and the prevalence of severe obesity (BMI ≥40) also increased from 3.1% to 6.9% for men and from 6.2% to 9.7% for women. The greatest increases in obesity prevalence have been among Mexican American men compared with non-Hispanic White men. Although obesity and severe obesity increased in all subgroups, the prevalence of both are greater among non-Hispanic Black women (56.9% and 18.9%, respectively) and Mexican American women (49.6% and 14.5%) compared with non-Hispanic White women (39.8% and 11.3%).

In the study by Muntner et al,2 the estimated proportion of adults with hypertension who had controlled blood pressure increased from 31.8% in 1999-2000 to 48.5% in 2007-2008, and then remained stable until 2013-2014, but significantly declined to 43.7% in 2017-2018. This observation underlines the importance of regular health care. A major difference in controlled hypertension was observed between those who had a health care visit in the past year vs those who had not (49.1% vs 8%, respectively). As noted in past studies, non-Hispanic Black adults vs non-Hispanic White adults continued to have a lower blood pressure control rate (41.5% vs 48.2%, respectively). The increasing prevalence of obesity and subsequent development of type 2 diabetes, and the lack of progress in hypertension control, may contribute to the apparent slowing of further progress in reducing cardiovascular mortality that has occurred since 2011, as well as a failure to ameliorate racial disparities in cardiovascular disease mortality.7

In addition to race/ethnicity and health care use, geographic location (eg, the stroke belt in the Southeastern US), rurality, and low socioeconomic status are also associated with increased risk of obesity and poor control of cardiovascular disease risk factors.8,9 What brings these disparities into sharper focus, and provides increased urgency for addressing them, is the ongoing severe acute respiratory syndrome coronavirus 2 pandemic and the risk for potentially life-threatening outcomes from coronavirus disease 2019 (COVID-19).

The presence of obesity, type 2 diabetes, chronic kidney disease, or cardiovascular disease are known risk factors for severe illness from COVID-19 in persons of any age.10 Black, Hispanic/Latino, American Indian/Alaska Native, and Pacific Islander individuals also have increased rates of infection and disproportionately poor outcomes from COVID-19, including higher risk of death than non-Hispanic White individuals.11

The confluence of these disturbing trends in obesity, hypertension, and COVID-19 within communities of color appears to reflect a complex interplay of contributing factors that are rooted in the social determinants of health and structural racism. Structural racism can be defined as the totality of ways (ie, policies, cultural norms) that society fosters racial discrimination via inequitable systems (eg, housing, education, employment, earnings, credit, and health care) that mutually reinforce and systematically perpetuate racial inequities.12

There is substantial evidence that the propensity to develop obesity across the lifespan is strongly shaped by the built environment and social context in which a child is born, grows, and ages. Studies indicate that minority children who are born and raised in racially segregated communities characterized by a high density of fast food outlets, limited access to fresh fruits and vegetables, and poor walkability are more likely to develop obesity and hypertension. These communities of color with high health disparities are part of the legacy of structural racism shaped by governmental policies such as redlining that discouraged capital investment needed to build vibrant and healthy communities.

The devastating effects of COVID-19 on communities of color is tightly related to this same intersectionality between race and class that increases exposure to the COVID-19 pandemic related to employment in essential service sectors and limited capacity to physically distance in crowded housing conditions. Addressing these complex drivers of health disparities will necessitate an approach that recognizes the multidimensional nature of contextual factors that led to structural racism, and advances the understanding of how these social factors promote comorbidities such as obesity and hypertension.

The National Institutes of Health (NIH) is firmly committed to supporting research to understand and ameliorate the causes and consequences of diseases that disproportionately affect minority and other underserved populations. Inequities in the social determinants of health early in life can have lifelong biological, behavioral, and psychosocial consequences, including increased likelihood of obesity, type 2 diabetes, and cardiovascular disease.13 Therefore, a life-course approach to addressing health disparities from the prenatal period through older adulthood offers multiple opportunities to develop and implement effective prevention and treatment strategies. Because many diseases within the missions of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the National Heart, Lung, and Blood Institute (NHLBI) place disparate burdens on minority and economically disadvantaged populations, both institutes have worked together to implement a life-course approach in diverse populations with high levels of disparities.14,15

Approaches targeting individual health behaviors to reduce the risk of obesity and cardiovascular disease in isolation of the broader social and environmental context may be less likely to have meaningful benefit than those that intervene at multiple levels. Multilevel approaches include policy, environmental, and community interventions15 and those engaging nontraditional partners outside the health care system to address areas such as early care and education, housing insecurity, and income inequality.16 In addition, research to reduce health disparities also benefits from a spectrum of approaches, ranging from basic studies to elucidate the biological factors that may increase susceptibility to disease or response to treatment, through precision prevention strategies using big data sources with omics data linked to phenotypic information to identify, for example, nutritional approaches for disease prevention.17-19 Increased use of big data resources and platforms could enable better development and implementable strategies for more effective and targeted prevention and treatment of both obesity and hypertension. The NIH is also committed to research programs designed to understand and ameliorate the racial/ethnic disparities in COVID-19. Both the NIDDK and the NHLBI also support digital health care interventional research to address social, economic, and behavioral outcomes associated with COVID-19 in vulnerable populations.20

Engaging patients, health advocacy organizations, families, community members, and others in research is another important approach to reduce health disparities. Including these groups as study partners from design and implementation through returning results to participants could help ensure that the research conducted addresses meaningful outcomes and strengthens all aspects of the research. The NIDDK and the NHLBI are working to increase broad engagement in research. Both institutes are also committed to promoting a talented and diverse scientific workforce through programs to support the training and career development of underrepresented scientists at all career stages. Both of these themes are highlighted in the strategic planning of the NIDDK, the NHLBI, and other institutes.21,22

The NIH is committed to evaluating the success of interventional studies to reduce the risk factors that contribute to mortality among racial/ethnic minority groups, including uncontrolled blood pressure and obesity, and to monitor the magnitude of these contributing factors and subsequent outcomes in epidemiological studies. A robust effort is also underway to evaluate NIH policies and practices that may act as barriers or facilitators in the creation of a diverse scientific workforce at all career levels and to monitor and report on the success or failure of underrepresented racial/ethnic minority investigators when competing for NIH funding.23

If the US is committed to changing the trend line of health disparities in obesity and hypertension, it is critical to acknowledge the important contributions of systemic racism and the social determinants of health in the context of the current COVID-19 crisis. It will take a collective, committed effort at every level, including policy makers, frontline community organizations, health care workers at safety-net clinics, and those conducting behavioral and biomedical scientific research, to address these potentially remediable contributors to some of the nation’s most complex health challenges. Only then will it be possible to achieve a vision of health equity in which each child born in the US is destined to live a full and healthy life regardless of their family’s zip code.

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Article Information

Corresponding Author: Griffin P. Rodgers, MD, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892 (griffinr@extra.niddk.nih.gov).

Published Online: September 9, 2020. doi:10.1001/jama.2020.16753

Conflict of Interest Disclosures: None reported.

References
1.
Ogden  CL, Fryar  CD, Martin  CB,  et al.  Trends in obesity prevalence by race and Hispanic origin—1999-2000 to 2017-2018.   JAMA. Published online August 28, 2020. doi:10.1001/jama.2020.14590Google Scholar
2.
Muntner  P, Hardy  ST, Fine  LJ,  et al.  Trends in blood pressure control among US adults with hypertension, 1999-2000 to 2017-2018.   JAMA. Published online September 9, 2020. doi:10.1001/jama.2020.14545Google Scholar
3.
US Centers for Disease Control and Prevention, National Center for Health Statistics. National Health and Nutrition Examination Survey. Accessed August 26, 2020. https://www.cdc.gov/nchs/nhanes/about_nhanes.htm
4.
Malhotra  R, Nguyen  HA, Benavente  O,  et al.  Association between more intensive vs less intensive blood pressure lowering and risk of mortality in chronic kidney disease stages 3 to 5: a systematic review and meta-analysis.   JAMA Intern Med. 2017;177(10):1498-1505. doi:10.1001/jamainternmed.2017.4377PubMedGoogle ScholarCrossref
5.
Jensen  MD, Ryan  DH, Apovian  CM,  et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Obesity Society.  2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society.   Circulation. 2014;129(25)(suppl 2):S102-S138. doi:10.1161/01.cir.0000437739.71477.eePubMedGoogle ScholarCrossref
6.
Linder  BL, Fradkin  JE, Rodgers  GP.  The TODAY study: an NIH perspective on its implications for research.   Diabetes Care. 2013;36(6):1775-1776. doi:10.2337/dc13-0707 PubMedGoogle ScholarCrossref
7.
Sidney  S, Quesenberry  CP  Jr, Jaffe  MG,  et al.  Recent trends in cardiovascular mortality in the United States and public health goals.   JAMA Cardiol. 2016;1(5):594-599. doi:10.1001/jamacardio.2016.1326PubMedGoogle ScholarCrossref
8.
Schultz  WM, Kelli  HM, Lisko  JC,  et al.  Socioeconomic status and cardiovascular outcomes: challenges and interventions.   Circulation. 2018;137(20):2166-2178. doi:10.1161/CIRCULATIONAHA.117.029652PubMedGoogle ScholarCrossref
9.
Hales  CM, Fryar  CD, Carroll  MD, Freedman  DS, Aoki  Y, Ogden  CL.  Differences in obesity prevalence by demographic characteristics and urbanization level among adults in the United States, 2013-2016.   JAMA. 2018;319(23):2419-2429. doi:10.1001/jama.2018.7270PubMedGoogle ScholarCrossref
10.
US Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): people with certain medical conditions. Accessed August 26, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html
11.
Webb Hooper  M, Nápoles  AM, Pérez-Stable  EJ.  COVID-19 and racial/ethnic disparities.   JAMA. 2020;323(24):2466-2467. doi:10.1001/jama.2020.8598PubMedGoogle ScholarCrossref
12.
Metzl  JM, Maybank  A, De Maio  F.  Responding to the COVID-19 pandemic: the need for a structurally competent health care system.   JAMA. 2020;324(3):231-232. doi:10.1001/jama.2020.9289PubMedGoogle ScholarCrossref
13.
Suglia  SF, Campo  RA, Brown  AGM,  et al.  Social determinants of cardiovascular health: early life adversity as a contributor to disparities in cardiovascular diseases.   J Pediatr. 2020;219:267-273. doi:10.1016/j.jpeds.2019.12.063PubMedGoogle ScholarCrossref
14.
Roberts  BT, Rodgers  GP.  NIDDK initiatives addressing health disparities in chronic diseases.   J Clin Invest. Published online August 24, 2020. doi:10.1172/JCI14153 PubMedGoogle Scholar
15.
Mensah  GA, Cooper  RS, Siega-Riz  AM,  et al.  Reducing cardiovascular disparities through community-engaged implementation research: a National Heart, Lung, and Blood Institute workshop report.   Circ Res. 2018;122(2):213-230. doi:10.1161/CIRCRESAHA.117.312243PubMedGoogle ScholarCrossref
16.
Marmot  M, Allen  JJ.  Social determinants of health equity.   Am J Public Health. 2014;104(suppl 4):S517-S519. doi:10.2105/AJPH.2014.302200PubMedGoogle ScholarCrossref
17.
National Heart, Lung and Blood Institute. NHLBI trans-omics for precision medicine. Accessed August 26, 2020. https://www.nhlbiwgs.org/
18.
National Heart, Lung and Blood Institute. NHLBI BioData Catalyst. Accessed August 26, 2020. https://biodatacatalyst.nhlbi.nih.gov/
19.
Rodgers  GP, Collins  FS.  Precision nutrition—the answer to “what to eat to stay healthy”.   JAMA. 2020;324(8):735-736. doi:10.1001/jama.2020.13601PubMedGoogle ScholarCrossref
20.
National Institutes of Health. Notice of special interest (NOSI): digital healthcare interventions to address the secondary health effects related to social, behavioral, and economic impact of COVID-19. Accessed August 26, 2020. https://grants.nih.gov/grants/guide/notice-files/not-mh-20-053.html
21.
National Institutes of Health. Request for information: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) strategic plan. Accessed August 26, 2020. https://grants.nih.gov/grants/guide/notice-files/NOT-DK-20-015.html
22.
US Department of Health and Human Services, National Heart, Lung, and Blood Institute. Charting the future together: the NHLBI strategic vision. Accessed August 26, 2020. https://www.nhlbi.nih.gov/sites/default/files/2017-11/NHLBI-Strategic-Vision-2016_FF.pdf
23.
National Institutes of Health. Advisory Committee to the Director Working Group on Diversity: 2018 recommendations. Accessed August 26, 2020. https://acd.od.nih.gov/documents/presentations/acd-wgd-report-2018.pdf
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