Abstract
Background
Obesity is a global epidemic. The prevalence of obesity has significantly increased in recent decades and is expected to impact a large portion of the US population. Hypertension continues to be one of the most common complications associated with obesity, and the overlap between these two conditions has been growing over time. However, mortality trends in patients with obesity and hypertension have not been investigated in the literature.
Objectives
This study aimed to investigate mortality trends, stratified by sex, race, age groups, and geographic distribution, in the US population between 1999 and 2020.
Methods
Death certificates from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) were examined and analyzed between 1999 and 2020 for patients with obesity and hypertension as the contributing causes of death. The age-adjusted mortality rates (AAMRs) and annual percent changes (APCs) per 100000 people were calculated by sex, race, age group, and geographic region.
Results
Among individuals aged ≥15, a total of 294854 deaths occurred in individuals with obesity and hypertension between 1999 and 2020. The overall AAMR increased from 1.08 in 1999 to 12.14 in 2020. The AAMR has steadily increased since 1999, with a sudden spike occurring between 2018 and 2020 during the COVID-19 pandemic. This trend has been observed across nearly all variables analyzed in our study. Our results exhibited a 28% increase in mortality related to obesity and hypertension during the early years of the COVID-19 pandemic. During the study period, men had a higher overall AAMR than women (men, 5.92; women, 4.32). Mortality was highest among the 55-74-year-old age group, followed by the 75-plus-year-old, 35-54-year-old, and finally 15-34-year-old age groups, which displayed the lowest AAMR (AAMR: 55-74, 11.76; 75+, 10.83; 35-54, 4.73; and 15-34, 0.54). Among the races, non-Hispanic (NH) Blacks had the highest overall AAMR (9.81), followed by NH American Indians or Alaskan Natives (6.01), NH Whites (4.64), Hispanics (4.08), and NH Asians or Pacific Islanders (1.17). However, NH Whites showed the highest average APC (AAPC) (11.44), indicating a possible future shift in mortality. By geographic region, the Southern United States had the highest AAMR, followed by the Western, Midwestern, and Northeastern regions. Non-metropolitan areas had consistently higher obesity- and hypertension-related AAMRs (5.63 overall) compared to metropolitan areas (4.99 overall).
Conclusion
In our retrospective analysis of death certificate data from 1999 to 2020, we found that age-adjusted mortality rates among individuals with both obesity and hypertension consistently displayed an increasing trend across all demographic groups. The overall rising AAMRs, compounded by the disproportionately high average annual percent changes among White individuals and those aged 15-34, raise serious concerns for the healthcare system. These findings have significant implications for public health policy. Focused interventions are essential to curb the upward trajectory of mortality in this population, as early intervention can greatly help tackle the dual burden of obesity and hypertension, which are largely preventable.
Keywords: age-adjusted mortality rates, cdc wonder, covid-19 pandemic, demographic differences, geographic variation, health disparities, hypertension, mortality trends, obesity
Introduction
Obesity affects over one billion individuals worldwide and was associated with nearly five million deaths in 2019, making it one of the leading contributors to global mortality [1]. With a brief hiatus between 2009 and 2012, obesity prevalence in the United States has continued to rise, with projections indicating that 78% of Americans will be overweight or obese by 2030 [2]. Additionally, approximately 47.3% of adults (116 million individuals) in the United States are affected by hypertension, with rates steadily rising since 2013 [3]. Among all modifiable risk factors, hypertension contributes most significantly to the burden of cardiovascular disease in the United States [4].
The prevalence of obesity in American adults with hypertension increased from 39.6% in 2001 to 55.4% in 2023 [5]. In a study done by Forman et al., an increased BMI significantly increases the risk of developing hypertension. Obese women were found to have a 4.7 times greater incidence of hypertension compared to those with a BMI lower than 23.0 kg/m² [6].
The mechanisms underlying obesity-related hypertension are complex and involve the dysregulation of the sympathetic nervous system, insulin resistance, renal structural and hemodynamic changes, and the renin-angiotensin-aldosterone system [7]. Microcirculation changes driven by dysfunctional and inflammatory perivascular adipose tissue (PVAT) in obesity contribute to impaired vascular tone regulation and are a major factor in the development of hypertension [8].
While previous studies have examined mortality trends in patients with obesity and hypertension separately, the trends related to the combination of both conditions have not been adequately investigated in the United States. Understanding the mortality with these coexisting conditions is essential to identifying high-risk groups and guiding targeted preventative interventions. Therefore, this study aims to characterize population-level mortality trends among US adults with concurrent obesity and hypertension, stratified by sex, race/ethnicity, age group, urbanization level, and geographic region.
Materials and methods
Study setting and population
This study utilized data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC) WONDER database, covering the period from January 1, 1999, to December 31, 2020 [9]. We analyzed death certificates from the Multiple Cause-of-Death Public Use records to identify cases involving both obesity and hypertension. Relevant deaths were defined as those in which both obesity and hypertensive diseases were listed as contributing or underlying causes of death. We identified cases of obesity using the International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code E66 [10]. Hypertensive diseases were classified using codes I10-I15, including essential (primary) hypertension, hypertensive heart disease, hypertensive chronic kidney disease, hypertensive heart and chronic kidney disease, and secondary hypertension. The study population consisted of individuals aged 15 years and older. Mortality rates were calculated using bridged-race population estimates provided by the US Census Bureau. Data were stratified into 10-year age groups (15-24, 25-34, 35-44,…, 85+). Age-adjusted mortality rates (AAMRs) were calculated using the direct method and standardized to the 2000 US standard population. Results are reported per 100000 persons with two decimal places of precision.
Data abstraction
We gathered data on deaths associated with obesity and hypertensive diseases, which included demographic information, population sizes, the year of death, and geographic location. Data were extracted using the CDC WONDER online query system with both ICD-10 codes applied simultaneously using the AND operator, ensuring that only deaths with concurrent obesity and hypertensive disease were captured. Additional information included urban-rural classifications, states, regional categories, and the locations of death (medical facility, home, hospice, or nursing home/long-term care facility). The urban-rural classifications followed the National Center for Health Statistics Urban-Rural Classification Scheme. The geographic regions were categorized according to the US Census Bureau divisions: Northeast, Midwest, South, and West.
Race and ethnicity were recorded from death certificates, in accordance with the US Office of Management and Budget standards. Racial and ethnic groups included Hispanic, non-Hispanic (NH) White, NH Black or African American, NH American Indian or Alaskan Native, and NH Asian or Pacific Islander [11].
Statistical analysis
To assess national trends in obesity-related and hypertensive disease-related mortality, we calculated crude mortality rates and age-adjusted mortality rates (AAMRs) per 100000 population from 1999 to 2020. These rates were stratified by year, sex, race, state, and region. Crude mortality rates were determined by dividing the number of deaths related to obesity and hypertensive disease by the corresponding US population for each year. AAMRs were calculated by standardizing deaths to the 2000 US population. We reported 95% confidence intervals (CIs) for all rates. Data for NH American Indian or Alaska Native populations in 1999 were excluded from trend analyses because the death count fell below the CDC WONDER reliability threshold of 20 deaths. All other suppressed or statistically unreliable cells (flagged by CDC WONDER) were similarly excluded from subgroup trend analyses.
To analyze temporal trends, we used the Joinpoint Regression Program (National Cancer Institute), which identifies significant changes by fitting log-linear regression models across time segments [12]. To calculate the annual trends in deaths associated with obesity and hypertensive disease, we assessed the annual percent change (APC), the average annual percent change (AAPC), and relative 95% CIs.
A trend was defined as increasing or decreasing if the slope differed significantly from zero, with significance assessed using two-tailed t-tests. A p-value of ≤0.05 was considered statistically significant.
Using AAPC numbers from 1999 to 2019, we estimated the expected AAMR for 2020, the first year of the pandemic. By comparing the estimated rate to the actual AAMR observed in 2020, we calculated the excess AAMR. To estimate the proportion of excess AAMR attributable to the pandemic, we divided the excess AAMR by the actual 2020 AAMR and reported the result as a percentage. Lastly, to estimate the extra death toll, we multiplied the actual number of deaths in 2020 by the proportion of excess AAMR.
Ethical considerations
This analysis used publicly available, de-identified data from federal databases and did not involve direct human-subject participation. As such, it was exempt from institutional review board (IRB) oversight following US federal research regulations.
Results
A total of 294854 deaths occurred between 1999 and 2020 that were attributed to obesity and hypertensive diseases among individuals aged ≥15 years (Table 1).
Table 1. Mortality in Obese Individuals With Hypertensive Diseases, Stratified by Sex, Ethnicity, Race, Age Groups, and Census Regions in the United States (1999-2020).
| Year | Overall | Male | Female | Hispanic or Latino | Not Hispanic or Latino | White | Black or African American | American Indian or Alaska Native | Asian or Pacific Islander | 15-34 | 35-54 | 55-74 | 75+ | Census Region 1: Northeast | Census Region 2: Midwest | Census Region 3: South | Census Region 4: West |
| 1999 | 2365 | 1048 | 1317 | 115 | 2239 | 1711 | 629 | 10 | 15 | 109 | 817 | 1053 | 386 | 418 | 520 | 800 | 627 |
| 2000 | 4663 | 2184 | 2479 | 216 | 4427 | 3513 | 1092 | 27 | 31 | 142 | 1651 | 2062 | 808 | 813 | 1040 | 1743 | 1067 |
| 2001 | 4854 | 2307 | 2547 | 246 | 4590 | 3635 | 1167 | 32 | 20 | 164 | 1753 | 2127 | 810 | 838 | 1067 | 1855 | 1094 |
| 2002 | 5766 | 2787 | 2979 | 285 | 5459 | 4299 | 1389 | 42 | 36 | 224 | 2057 | 2550 | 935 | 950 | 1233 | 2126 | 1457 |
| 2003 | 6616 | 3218 | 3398 | 377 | 6215 | 4987 | 1534 | 49 | 46 | 241 | 2369 | 2977 | 1029 | 1030 | 1377 | 2552 | 1657 |
| 2004 | 7174 | 3584 | 3590 | 396 | 6754 | 5330 | 1742 | 52 | 50 | 264 | 2558 | 3320 | 1032 | 1165 | 1507 | 2762 | 1740 |
| 2005 | 7946 | 4009 | 3937 | 405 | 7526 | 5994 | 1810 | 64 | 78 | 306 | 2735 | 3705 | 1200 | 1252 | 1735 | 3017 | 1942 |
| 2006 | 8445 | 4313 | 4132 | 532 | 7886 | 6392 | 1893 | 91 | 69 | 299 | 2949 | 3899 | 1298 | 1338 | 1751 | 3297 | 2059 |
| 2007 | 9186 | 4811 | 4375 | 605 | 8563 | 6985 | 2027 | 76 | 98 | 341 | 3232 | 4302 | 1311 | 1574 | 1851 | 3449 | 2312 |
| 2008 | 10032 | 5250 | 4782 | 630 | 9366 | 7638 | 2177 | 91 | 126 | 367 | 3511 | 4708 | 1446 | 1690 | 2155 | 3745 | 2442 |
| 2009 | 11223 | 6031 | 5192 | 824 | 10332 | 8538 | 2447 | 140 | 98 | 427 | 3936 | 5352 | 1508 | 1928 | 2245 | 4441 | 2609 |
| 2010 | 11954 | 6491 | 5463 | 848 | 11052 | 9113 | 2575 | 138 | 128 | 433 | 4045 | 5817 | 1659 | 2134 | 2468 | 4579 | 2773 |
| 2011 | 13341 | 7246 | 6095 | 980 | 12307 | 10287 | 2775 | 133 | 146 | 479 | 4464 | 6506 | 1892 | 2293 | 2913 | 4965 | 3170 |
| 2012 | 14746 | 8066 | 6680 | 1073 | 13600 | 11354 | 3077 | 170 | 145 | 515 | 4720 | 7382 | 2129 | 2535 | 3164 | 5665 | 3382 |
| 2013 | 15741 | 8654 | 7087 | 1233 | 14439 | 12171 | 3257 | 176 | 137 | 497 | 4945 | 8013 | 2286 | 2613 | 3477 | 6134 | 3517 |
| 2014 | 17199 | 9617 | 7582 | 1351 | 15754 | 13264 | 3530 | 215 | 190 | 586 | 5306 | 8786 | 2521 | 2814 | 3903 | 6739 | 3743 |
| 2015 | 18702 | 10518 | 8184 | 1458 | 17127 | 14365 | 3901 | 190 | 246 | 624 | 5605 | 9761 | 2712 | 3117 | 4238 | 7239 | 4108 |
| 2016 | 19867 | 11136 | 8731 | 1599 | 18153 | 15228 | 4178 | 247 | 214 | 629 | 5976 | 10424 | 2838 | 3243 | 4404 | 7807 | 4413 |
| 2017 | 20993 | 12007 | 8986 | 1722 | 19148 | 16254 | 4238 | 239 | 262 | 689 | 6026 | 11172 | 3106 | 3392 | 4597 | 8294 | 4710 |
| 2018 | 22515 | 13064 | 9451 | 1798 | 20609 | 17427 | 4532 | 275 | 281 | 720 | 6140 | 12037 | 3582 | 3560 | 4978 | 8961 | 5016 |
| 2019 | 24117 | 13993 | 10124 | 2003 | 22021 | 18594 | 4911 | 309 | 303 | 767 | 6352 | 12974 | 4024 | 3724 | 5269 | 9991 | 5133 |
| 2020 | 37409 | 21202 | 16207 | 4601 | 32704 | 28009 | 8319 | 541 | 540 | 1109 | 9444 | 20248 | 6608 | 5531 | 8154 | 15910 | 7814 |
| Total | 294854 | 161536 | 133318 | 23297 | 270271 | 225088 | 63200 | 3307 | 3259 | 9932 | 90591 | 149211 | 45120 | 47952 | 64046 | 116071 | 66785 |
The AAMR increased from 1.08 (95% CI: 1.04-1.13) in 1999 to 12.14 (95% CI: 12.01-12.26) in 2020 (Figure 1, Table 2, and Table 3). There has been a steady rise in AAMR since 1999, with a sudden spike after 2018. This spike in AAMR from 2019 was consistent among most groups. The cumulative AAPC for our cohort was +8.59 (95% CI: 7.00-10.2) (Table 3). The 2018-2020 APC reflects a short-term deviation from the longer pre-pandemic trend. The excess mortality analysis, which projects the expected 2020 AAMR based on the 1999-2019 pre-pandemic trajectory, provides a more appropriate framework for evaluating the impact of the COVID-19 pandemic on mortality in this population.
Table 2. Overall and Sex-Stratified Age-Adjusted Mortality Rates per 100000 in Obese Individuals With Hypertensive Diseases in the United States (1999-2020).
CI: confidence interval
| Year | Female (95% CI) | Male (95% CI) | Overall (95% CI) |
| 1999 | 1.12 (1.05-1.18) | 1.05 (0.98-1.11) | 1.08 (1.04-1.13) |
| 2000 | 2.08 (2.00-2.16) | 2.12 (2.03-2.21) | 2.12 (2.06-2.18) |
| 2001 | 2.10 (2.02-2.18) | 2.19 (2.10-2.28) | 2.18 (2.11-2.24) |
| 2002 | 2.41 (2.32-2.50) | 2.62 (2.52-2.72) | 2.54 (2.48-2.61) |
| 2003 | 2.72 (2.63-2.81) | 2.93 (2.83-3.04) | 2.85 (2.78-2.92) |
| 2004 | 2.85 (2.76-2.95) | 3.20 (3.10-3.31) | 3.05 (2.98-3.12) |
| 2005 | 3.03 (2.94-3.13) | 3.49 (3.38-3.60) | 3.30 (3.22-3.37) |
| 2006 | 3.14 (3.04-3.24) | 3.68 (3.57-3.80) | 3.44 (3.36-3.51) |
| 2007 | 3.29 (3.19-3.38) | 4.04 (3.93-4.16) | 3.67 (3.59-3.75) |
| 2008 | 3.51 (3.41-3.61) | 4.33 (4.21-4.45) | 3.92 (3.85-4.00) |
| 2009 | 3.78 (3.68-3.89) | 4.86 (4.74-4.98) | 4.28 (4.20-4.36) |
| 2010 | 3.91 (3.80-4.01) | 5.18 (5.05-5.30) | 4.52 (4.44-4.60) |
| 2011 | 4.27 (4.16-4.38) | 5.70 (5.57-5.83) | 4.97 (4.89-5.06) |
| 2012 | 4.61 (4.50-4.73) | 6.21 (6.07-6.35) | 5.41 (5.32-5.50) |
| 2013 | 4.83 (4.72-4.95) | 6.57 (6.42-6.71) | 5.67 (5.58-5.76) |
| 2014 | 5.04 (4.93-5.16) | 7.21 (7.07-7.36) | 6.12 (6.02-6.21) |
| 2015 | 5.39 (5.27-5.51) | 7.71 (7.55-7.86) | 6.51 (6.42-6.61) |
| 2016 | 5.66 (5.54-5.78) | 8.09 (7.93-8.24) | 6.85 (6.75-6.95) |
| 2017 | 5.71 (5.59-5.83) | 8.56 (8.40-8.71) | 7.09 (6.99-7.19) |
| 2018 | 5.92 (5.80-6.04) | 9.20 (9.04-9.36) | 7.50 (7.40-7.60) |
| 2019 | 6.24 (6.12-6.37) | 9.73 (9.57-9.90) | 7.95 (7.85-8.06) |
| 2020 | 9.79 (9.63-9.95) | 14.58 (14.38-14.78) | 12.14 (12.01-12.26) |
| Total | 4.32 (4.30-4.34) | 5.92 (5.89-5.95) | 5.11 (5.09-5.13) |
Table 3. Annual Percent Change (APC) and Average Annual Percent Change (AAPC) of Age-Adjusted Mortality Rates per 100000 in Obese Individuals With Hypertensive Diseases (1999-2020).
CI: confidence interval
| Year interval | APC (95% CI) | AAPC (95% CI) |
| Overall | ||
| 1999-2018 | 7.31 (6.43-8.20) | 8.60 (7.00-10.22) |
| 2018-2020 | 21.65 (4.92-41.05) | |
| Males | ||
| 1999-2001 | 47.04 (25.94-71.68) | 12.34 (10.76-13.95) |
| 2001-2018 | 7.78 (7.46-8.11) | |
| Female | ||
| 1999-2018 | 6.08 (5.29-6.88) | 7.47 (5.89-9.07) |
| 2018-2020 | 21.54 (4.49-41.38) | |
| 15-34 years old | ||
| 1999-2002 | 47.57 (22.34-77.99) | 12.24 (9.20-15.37) |
| 2002-2018 | 5.81 (5.02-6.62) | |
| 2018-2020 | 19.35 (4.80-35.92) | |
| 35-54 years old | ||
| 1999-2001 | 36.17 (22.00-52.02) | 10.80 (9.54-12.07) |
| 2001-2015 | 7.88 (7.56-8.21) | |
| 2015-2018 | 1.31 (-2.95-5.76) | |
| 2018-2020 | 24.27 (19.68-29.04) | |
| 55-74 years old | ||
| 1999-2018 | 6.90 (6.14-7.67) | 8.34 (7.01-9.69) |
| 2018-2020 | 23.04 (8.89-39.05) | |
| 75+ years old | ||
| 1999-2018 | 7.39 (6.61-8.18) | 9.35 (7.92-10.80) |
| 2018-2020 | 29.88 (13.83-48.18) | |
| Hispanic | ||
| 1999-2018 | 6.64 (5.74-7.55) | 9.97 (8.54-11.43) |
| 2018-2020 | 47.29 (30.03-66.84) | |
| Non Hispanics | ||
| 1999-2001 | 39.84 (27.24-53.69) | 10.94 (9.94-11.60) |
| 2001-2018 | 6.92 (6.67-7.17) | |
| 2018-2020 | 20.46 (15.84-25.26) | |
| American Indian or Alaska Native | ||
| 2000-2018 | 7.24 (5.66-8.84) | 9.55 (7.04-12.13) |
| 2018-2020 | 32.82 (7.41-64.23) | |
| Asian or Pacific Islander | ||
| 2000-2020 | 9.05 (7.19-10.94) | 9.05 (7.19-10.94) |
| Black or African American | ||
| 1999-2018 | 5.44 (4.67-6.22) | 7.37 (5.87-8.90) |
| 2018-2020 | 27.57 (10.58-47.18) | |
| White | ||
| 1999-2001 | 42.27 (23.54-63.84) | 11.44 (9.96-12.93) |
| 2001-2018 | 7.26 (6.94-7.59) | |
| 2018-2020 | 20.77 (14.55-27.32) | |
| Census Region 1: Northeast | ||
| 1999-2011 | 9.92 (8.39-11.48) | 9.19 (7.51-10.91) |
| 2011-2018 | 4.55 (1.88-7.30) | |
| 2018-2020 | 22.08 (7.34-38.86) | |
| Census Region 2: Midwest | ||
| 1999-2020 | 8.83 (7.92-9.75) | 8.83 (7.92-9.75) |
| Census Region 3: South | ||
| 1999-2018 | 7.25 (6.47-8.05) | 8.89 (7.43-10.38) |
| 2018-2020 | 25.75 (9.75-44.07) | |
| Census Region 4: West | ||
| 1999-2003 | 18.73 (11.40-26.55) | 8.90 (7.45-10.38) |
| 2003-2018 | 4.99 (4.43-5.55) | |
| 2018-2020 | 20.60 (11.54-30.40) | |
| Urban | ||
| 1999-2018 | 7.29 (6.40-8.18) | 8.53 (6.69-10.40) |
| 2018-2020 | 21.12 (1.52-44.51) | |
| Rural | ||
| 1999-2001 | 47.95 (26.21-73.45) | 12.24 (10.60-13.90) |
| 2001-2018 | 7.45 (7.12-7.80) | |
| 2018-2020 | 23.28 (17.07-29.82) | |
Figure 1. Age-Adjusted Mortality Rates per 100000 Population in the United States From 1999 Through 2020, Overall and Stratified by Sex.
Data for the place of death were available for 294237 of these deaths, which showed that 44.99% occurred at home, 42.65% of the deaths occurred in medical facilities, 5.65% occurred at nursing homes/long-term care facilities, and 0.94% occurred at hospice (Table 4).
Table 4. Mortality in Obese Individuals With Hypertensive Diseases, Stratified by the Place of Death in the United States (1999-2020).
| Place of Death | Deaths |
| Medical facilities | 125492 |
| Decedent's home | 132383 |
| Hospice facility | 2757 |
| Nursing home/long-term care | 16645 |
| Others | 16960 |
| Place of death unknown | 617 |
| Total | 294854 |
In our study group, a significant portion of the total deaths, 161536 (54.79%), occurred in men. The Southern US regions accounted for 116072 (39.37%) of the total deaths. The non-Hispanic population contributed to an overwhelming 270271 (91.66%) deaths. Within this group, 225088 (76.34%) deaths were among White individuals, while Black individuals accounted for 63200 (22.43%) deaths. About 2.23% of the deaths were attributed to Indian/Alaska Native and Asian/Pacific Islander populations.
The age distribution revealed that 149211 (50.60%) deaths were recorded in the 55-74-year-old age group, followed by 90591 (30.72%) deaths in the 35-54-year-old age group and 45120 (15.30%) in the 75+ age group. The 15-34-year-old age group just accounted for 9932 (3.36%) deaths (Table 1).
Obesity and hypertension AAMR stratified by sex
Over the study period, men aged ≥15 years had a higher AAMR than women aged ≥15 years (overall AAMR: men = 5.92; 95% CI, 5.85-5.95; women = 4.32; 95% CI: 4.30-4.34). The AAPC was significantly higher in men (AAPC: +12.34%; 95% CI, 10.75-13.94) than in women (AAPC: +7.46%; 95% CI, 5.89-9.07) (Figure 1, Table 2, and Table 3).
Obesity and hypertension AAMR stratified by age groups
Mortality was highest among the 55-74-year-old age group, followed by 75-plus-year-old, 35-54-year-old, and finally 15-34-year-old age group (AAMR: 55-74: 11.76; 95% CI, 11.70-11.82; 75+: 10.83; 95% CI, 10.73-10.93; 35-54: 4.73; 95% CI, 4.70-4.76; and 15-34: 0.54; 95% CI, 0.53-0.56).
However, throughout the study, the younger age groups showed the highest overall rate of increase in AAMRs. The highest was demonstrated by the 15-34-year-old age group (AAPC: +12.24; 95% CI, 9.20-15.37); they were followed by 35-54 year olds (AAPC: +10.80; 95% CI, 9.54-12.07) and 75+ year olds (AAPC: +9.35; 95% CI, 7.92-10.80), and 55-74 year olds actually showed the lowest overall increase in AAMR (AAPC: +8.34; 95% CI, 7.01-9.69) (Figure 2, Table 3, and Table 5).
Table 5. Age-Adjusted Mortality Rates per 100000 in Obese Individuals With Hypertensive Diseases in the United States According to Age Groups (1999-2020).
CI: confidence interval
| Year | 15-34 Years Old (95% CI) | 35-54 Years Old (95% CI) | 55-74 Years Old (95% CI) | 75+ Years Old (95% CI) |
| 1999 | 0.10 (0.08-0.12) | 1.01 (0.94-1.08) | 2.47 (2.32-2.62) | 2.40 (2.16-2.64) |
| 2000 | 0.15 (0.12-0.17) | 1.97 (1.88-2.07) | 4.87 (4.66-5.08) | 4.84 (4.51-5.18) |
| 2001 | 0.20 (0.17-0.23) | 2.07 (1.97-2.17) | 4.90 (4.69-5.11) | 4.77 (4.44-5.09) |
| 2002 | 0.30 (0.26-0.34) | 2.41 (2.30-2.51) | 5.69 (5.47-5.91) | 5.44 (5.09-5.79) |
| 2003 | 0.30 (0.26-0.34) | 2.74 (2.63-2.85) | 6.42 (6.18-6.65) | 5.94 (5.58-6.31) |
| 2004 | 0.35 (0.31-0.39) | 2.93 (2.82-3.05) | 6.99 (6.75-7.23) | 5.89 (5.53-6.25) |
| 2005 | 0.40 (0.35-0.44) | 3.08 (2.96-3.19) | 7.54 (7.30-7.79) | 6.77 (6.38-7.15) |
| 2006 | 0.40 (0.35-0.44) | 3.28 (3.16-3.40) | 7.69 (7.44-7.93) | 7.21 (6.82-7.60) |
| 2007 | 0.45 (0.40-0.49) | 3.58 (3.45-3.70) | 8.20 (7.95-8.45) | 7.27 (6.87-7.66) |
| 2008 | 0.45 (0.40-0.49) | 3.86 (3.73-3.99) | 8.67 (8.42-8.92) | 7.96 (7.55-8.37) |
| 2009 | 0.50 (0.45-0.54) | 4.30 (4.16-4.43) | 9.47 (9.22-9.73) | 8.26 (7.85-8.68) |
| 2010 | 0.50 (0.45-0.54) | 4.45 (4.31-4.59) | 10.09 (9.83-10.35) | 8.99 (8.55-9.42) |
| 2011 | 0.54 (0.50-0.59) | 4.98 (4.83-5.12) | 10.86 (10.59-11.13) | 10.11 (9.65-10.57) |
| 2012 | 0.59 (0.54-0.65) | 5.32 (5.17-5.48) | 11.90 (11.63-12.18) | 11.23 (10.75-11.71) |
| 2013 | 0.54 (0.50-0.59) | 5.61 (5.46-5.77) | 12.48 (12.20-12.75) | 11.90 (11.41-12.39) |
| 2014 | 0.69 (0.64-0.75) | 6.05 (5.89-6.21) | 13.29 (13.01-13.57) | 12.88 (12.37-13.38) |
| 2015 | 0.69 (0.64-0.75) | 6.39 (6.22-6.55) | 14.36 (14.08-14.65) | 13.67 (13.15-14.19) |
| 2016 | 0.74 (0.69-0.80) | 6.88 (6.70-7.05) | 14.92 (14.63-15.21) | 13.99 (13.47-14.51) |
| 2017 | 0.74 (0.69-0.80) | 6.97 (6.79-7.14) | 15.63 (15.34-15.92) | 14.87 (14.35-15.40) |
| 2018 | 0.79 (0.74-0.85) | 7.17 (6.99-7.35) | 16.61 (16.31-16.90) | 16.54 (16.00-17.08) |
| 2019 | 0.84 (0.78-0.90) | 7.50 (7.32-7.69) | 17.58 (17.27-17.88) | 18.06 (17.50-18.62) |
| 2020 | 1.19 (1.12-1.26) | 11.16 (10.94-11.39) | 27.03 (26.66-27.40) | 28.85 (28.15-29.54) |
| Total | 0.54 (0.53-0.56) | 4.73 (4.70-4.76) | 11.76 (11.70-11.82) | 10.83 (10.73-10.93) |
Figure 2. Age-Adjusted Mortality Rates per 100000 Population From 1999 to 2020, Stratified by Age Group.
Mortality trends are shown for individuals aged 15-34 years (dark blue), 35-54 years (orange), 55-74 years (green), and 75 years and older (light blue).
Obesity and hypertension AAMR stratified by race and ethnicity
Mortality was higher in non-Hispanic populations as compared to Hispanic populations (AAMR: non-Hispanic = 5.22; 95% CI, 5.20-5.24; Hispanic = 4.08; 95% CI, 4.03-4.14). AAPCs were comparable in non-Hispanic (AAPC: +10.94; 95% CI, 9.94-11.95) and Hispanic populations (AAPC: +9.97; 95% CI, 8.53-11.42).
Among the non-Hispanic (NH) races, NH Black or African American had the highest overall AAMR (9.81; 95% CI, 9.74-9.89), followed by NH American Indian or Alaska Native (6.01; 95% CI, 5.80-6.23), NH White (4.64; 95% CI, 4.62-4.66), and finally NH Asian or Pacific Islander (1.17; 95% CI, 1.13-1.21).
However, the highest overall increase in AAMR throughout the study represented by AAPC was shown by NH White (AAPC: +11.44; 95% CI, 9.64-12.93); they were followed by NH American Indian or Alaska Native and NH Asian or Pacific Islander, which both showed similar values (AAPC: +9.56; 95% CI, 7.05-12.13; AAPC: +9.05; 95% CI, 7.19-10.94 respectively). Finally, NH Black or African American showed the lowest AAPC (+7.37; 95% CI, 5.87-8.90) (Figure 3, Table 3, and Table 6).
Table 6. Age-Adjusted Mortality Rates per 100000 in Obese Individuals With Hypertensive Diseases in the United States According to Race and Ethnicity (1999 to 2020).
CI: confidence interval
| Year | American Indian or Alaska Native (95% CI) | Asian or Pacific Islander (95% CI) | Black or African American (95% CI) | White (95% CI) | Hispanic or Latino (95% CI) | Not Hispanic or Latino (95% CI) |
| 1999 | Unreliable | Unreliable | 2.80 (2.58-3.03) | 0.90 (0.86-0.94) | 0.77 (0.62-0.92) | 1.14 (1.09-1.18) |
| 2000 | 1.94 (1.24-2.88) | 0.41 (0.27-0.58) | 4.86 (4.57-5.15) | 1.87 (1.81-1.94) | 1.35 (1.15-1.54) | 2.19 (2.13-2.26) |
| 2001 | 1.81 (1.21-2.60) | 0.22 (0.13-0.35) | 5.02 (4.73-5.31) | 1.87 (1.81-1.94) | 1.47 (1.28-1.67) | 2.24 (2.17-2.30) |
| 2002 | 2.65 (1.84-3.68) | 0.41 (0.29-0.58) | 5.79 (5.48-6.10) | 2.19 (2.12-2.26) | 1.60 (1.41-1.80) | 2.63 (2.56-2.70) |
| 2003 | 2.85 (2.04-3.86) | 0.53 (0.39-0.72) | 6.25 (5.93-6.57) | 2.54 (2.47-2.61) | 2.10 (1.87-2.32) | 2.92 (2.85-3.00) |
| 2004 | 2.71 (1.97-3.63) | 0.51 (0.38-0.68) | 6.92 (6.58-7.25) | 2.64 (2.57-2.71) | 1.99 (1.78-2.19) | 3.13 (3.06-3.21) |
| 2005 | 3.29 (2.49-4.26) | 0.77 (0.60-0.97) | 7.02 (6.69-7.35) | 2.93 (2.86-3.00) | 1.96 (1.76-2.17) | 3.41 (3.33-3.48) |
| 2006 | 4.19 (3.32-5.21) | 0.65 (0.50-0.83) | 7.10 (6.77-7.43) | 3.08 (3.00-3.16) | 2.44 (2.22-2.66) | 3.54 (3.46-3.62) |
| 2007 | 3.30 (2.55-4.20) | 0.87 (0.71-1.07) | 7.44 (7.11-7.77) | 3.31 (3.23-3.38) | 2.54 (2.33-2.76) | 3.79 (3.71-3.87) |
| 2008 | 3.88 (3.08-4.83) | 1.12 (0.91-1.32) | 7.72 (7.39-8.05) | 3.58 (3.50-3.66) | 2.63 (2.41-2.85) | 4.07 (3.99-4.16) |
| 2009 | 5.93 (4.86-6.99) | 0.78 (0.63-0.96) | 8.49 (8.15-8.84) | 3.91 (3.83-3.99) | 3.24 (3.01-3.48) | 4.43 (4.34-4.52) |
| 2010 | 5.14 (4.23-6.04) | 1.02 (0.84-1.21) | 8.73 (8.38-9.07) | 4.12 (4.04-4.21) | 3.29 (3.05-3.52) | 4.68 (4.59-4.76) |
| 2011 | 4.77 (3.91-5.62) | 1.11 (0.93-1.30) | 9.20 (8.85-9.55) | 4.58 (4.49-4.67) | 3.60 (3.36-3.84) | 5.13 (5.04-5.22) |
| 2012 | 6.01 (5.06-6.96) | 1.09 (0.91-1.27) | 10.02 (9.65-10.38) | 4.98 (4.89-5.07) | 3.74 (3.51-3.98) | 5.61 (5.51-5.71) |
| 2013 | 6.16 (5.21-7.11) | 0.96 (0.80-1.13) | 10.44 (10.07-10.80) | 5.27 (5.17-5.36) | 4.19 (3.94-4.43) | 5.88 (5.78-5.98) |
| 2014 | 7.53 (6.47-8.59) | 1.28 (1.09-1.46) | 10.92 (10.55-11.29) | 5.68 (5.58-5.78) | 4.29 (4.05-4.53) | 6.36 (6.26-6.46) |
| 2015 | 6.17 (5.26-7.08) | 1.63 (1.43-1.84) | 11.79 (11.41-12.17) | 6.03 (5.93-6.13) | 4.45 (4.21-4.69) | 6.78 (6.68-6.89) |
| 2016 | 8.05 (7.01-9.09) | 1.33 (1.15-1.51) | 12.34 (11.96-12.72) | 6.36 (6.25-6.46) | 4.75 (4.51-5.00) | 7.14 (7.03-7.25) |
| 2017 | 7.33 (6.37-8.29) | 1.57 (1.38-1.76) | 12.22 (11.85-12.60) | 6.66 (6.55-6.77) | 4.85 (4.61-5.08) | 7.43 (7.32-7.54) |
| 2018 | 8.25 (7.25-9.25) | 1.65 (1.45-1.84) | 12.94 (12.56-13.33) | 7.05 (6.94-7.15) | 4.88 (4.65-5.11) | 7.90 (7.79-8.01) |
| 2019 | 9.27 (8.21-10.34) | 1.69 (1.50-1.89) | 13.78 (13.38-14.17) | 7.43 (7.32-7.54) | 5.25 (5.01-5.49) | 8.32 (8.20-8.43) |
| 2020 | 15.72 (14.36-17.08) | 2.92 (2.67-3.17) | 22.85 (22.35-23.36) | 11.06 (10.92-11.19) | 12.07 (11.71-12.43) | 12.21 (12.07-12.35) |
| Total | 6.01 (5.80-6.23) | 1.17 (1.13-1.21) | 9.81 (9.74-9.89) | 4.64 (4.62-4.66) | 4.08 (4.03-4.14) | 5.22 (5.20-5.24) |
Figure 3. Age-Adjusted Mortality Rates per 100000 Population From 1999 to 2020, Stratified by Ethnicity (Top Panel) and Race (Bottom Panel).
The top panel shows Hispanic or Latino (blue) and not Hispanic or Latino (orange). The bottom panel shows American Indian or Alaska Native (green), Asian or Pacific Islander (orange), Black or African American (red), and White (blue).
Obesity and hypertension AAMR stratified by geographic region
Inspecting the trends, a substantial difference was observed in different states. When arranged by AAMR, states that fell in the top 90th percentile included Vermont, Oklahoma, the District of Columbia, West Virginia, Mississippi, and Rhode Island. States that fell into the bottom 10th percentile were Connecticut, Virginia, Massachusetts, Missouri, Maine, and Nebraska. Vermont exhibited the highest overall AAMR at 12.44 (95% CI: 11.83-13.05), more than four times that of Connecticut, with the lowest AAMR at 2.67 (95% CI: 2.55-2.8) (Table 7).
Table 7. Age-Adjusted Mortality Rates per 100000 in Obese Individuals With Hypertensive Diseases in the United States, by State (1999-2020).
CI: confidence interval
| State | Age Adjusted Rate (95% CI) |
| Alabama | 2.78 (2.67-2.89) |
| Alaska | 5.99 (5.50-6.48) |
| Arizona | 4.38 (4.26-4.50) |
| Arkansas | 4.44 (4.26-4.62) |
| California | 5.33 (5.28-5.39) |
| Colorado | 6.31 (6.15-6.48) |
| Connecticut | 2.67 (2.55-2.80) |
| Delaware | 7.07 (6.67-7.47) |
| District of Columbia | 9.62 (9.02-10.21) |
| Florida | 4.45 (4.38-4.51) |
| Georgia | 5.28 (5.17-5.40) |
| Hawaii | 4.23 (3.98-4.49) |
| Idaho | 4.59 (4.33-4.84) |
| Illinois | 3.9 (3.82-3.98) |
| Indiana | 4.95 (4.82-5.07) |
| Iowa | 5.9 (5.71-6.10) |
| Kansas | 4.25 (4.07-4.42) |
| Kentucky | 5.52 (5.36-5.68) |
| Louisiana | 6.19 (6.02-6.37) |
| Maine | 3.8 (3.57-4.03) |
| Maryland | 4.82 (4.68-4.95) |
| Massachusetts | 2.93 (2.84-3.03) |
| Michigan | 5.31 (5.21-5.41) |
| Minnesota | 5.88 (5.73-6.03) |
| Mississippi | 7.14 (6.91-7.37) |
| Missouri | 3.67 (3.56-3.79) |
| Montana | 5.36 (5.03-5.68) |
| Nebraska | 3.75 (3.55-3.96) |
| Nevada | 5.45 (5.24-5.66) |
| New Hampshire | 4.05 (3.81-4.30) |
| New Jersey | 3.86 (3.76-3.95) |
| New Mexico | 5.55 (5.31-5.79) |
| New York | 5.31 (5.23-5.38) |
| North Carolina | 5.67 (5.56-5.79) |
| North Dakota | 5.81 (5.40-6.23) |
| Ohio | 5.55 (5.45-5.65) |
| Oklahoma | 10.87 (10.63-11.12) |
| Oregon | 5.08 (4.92-5.24) |
| Pennsylvania | 4.1 (4.02-4.18) |
| Rhode Island | 6.86 (6.50-7.22) |
| South Carolina | 5.35 (5.20-5.51) |
| South Dakota | 4.32 (3.99-4.65) |
| Tennessee | 6.46 (6.32-6.61) |
| Texas | 6.46 (6.38-6.54) |
| Utah | 4.05 (3.85-4.25) |
| Vermont | 12.44 (11.83-13.05) |
| Virginia | 2.86 (2.77-2.94) |
| Washington | 4.7 (4.58-4.82) |
| West Virginia | 7.08 (6.80-7.36) |
| Wisconsin | 6.74 (6.59-6.90) |
| Wyoming | 6.53 (6.04-7.03) |
During the study period between 1999 and 2020, overall AAMR was highest in the Southern US region, followed by the Western, Midwestern, and Northeast US regions. In terms of AAPC values, all four regions exhibited similar values; however, the Northeast region showed the highest AAPC (Northeast AAPC: +9.19; 95% CI, 7.51-10.90; West AAPC: +8.90; 95% CI, 7.45-10.38; South AAPC: +8.89; 95% CI, 7.42-10.38; and Midwest AAPC: +8.83; 95% CI, 7.92-9.75) (Figure 4, Table 3, and Table 8).
Table 8. Age-Adjusted Mortality Rates per 100000 in Obese Individuals With Hypertensive Diseases in the United States According to Census Regions (1999-2020).
CI: confidence interval
| Year | Census Region 1: Northeast (95% CI) | Census Region 2: Midwest (95% CI) | Census Region 3: South (95% CI) | Census Region 4: West (95% CI) |
| 1999 | 0.96 (0.86-1.05) | 1.04 (0.95-1.13) | 1.06 (0.99-1.14) | 1.40 (1.29-1.51) |
| 2000 | 1.85 (1.72-1.97) | 2.06 (1.94-2.19) | 2.24 (2.14-2.35) | 2.34 (2.20-2.48) |
| 2001 | 1.87 (1.74-2.00) | 2.09 (1.97-2.22) | 2.32 (2.21-2.43) | 2.33 (2.20-2.47) |
| 2002 | 2.12 (1.98-2.25) | 2.40 (2.27-2.53) | 2.60 (2.49-2.71) | 3.00 (2.84-3.15) |
| 2003 | 2.27 (2.13-2.41) | 2.62 (2.48-2.76) | 3.04 (2.92-3.16) | 3.33 (3.16-3.49) |
| 2004 | 2.52 (2.38-2.67) | 2.79 (2.65-2.93) | 3.23 (3.10-3.35) | 3.41 (3.25-3.57) |
| 2005 | 2.69 (2.54-2.84) | 3.19 (3.04-3.34) | 3.42 (3.30-3.55) | 3.70 (3.54-3.87) |
| 2006 | 2.83 (2.67-2.98) | 3.17 (3.02-3.32) | 3.67 (3.54-3.80) | 3.85 (3.69-4.02) |
| 2007 | 3.30 (3.13-3.46) | 3.29 (3.14-3.44) | 3.77 (3.65-3.90) | 4.18 (4.01-4.35) |
| 2008 | 3.51 (3.34-3.68) | 3.82 (3.65-3.98) | 4.01 (3.88-4.14) | 4.33 (4.16-4.51) |
| 2009 | 3.93 (3.75-4.10) | 3.89 (3.73-4.05) | 4.63 (4.49-4.77) | 4.48 (4.31-4.66) |
| 2010 | 4.30 (4.11-4.48) | 4.26 (4.09-4.43) | 4.70 (4.57-4.84) | 4.74 (4.56-4.92) |
| 2011 | 4.56 (4.37-4.75) | 4.93 (4.75-5.11) | 5.04 (4.90-5.19) | 5.26 (5.07-5.44) |
| 2012 | 4.95 (4.76-5.15) | 5.27 (5.09-5.46) | 5.62 (5.47-5.77) | 5.50 (5.32-5.69) |
| 2013 | 5.04 (4.84-5.24) | 5.78 (5.58-5.97) | 5.99 (5.84-6.14) | 5.60 (5.41-5.78) |
| 2014 | 5.37 (5.17-5.58) | 6.42 (6.22-6.63) | 6.45 (6.29-6.61) | 5.81 (5.62-6.00) |
| 2015 | 5.90 (5.68-6.11) | 6.87 (6.66-7.09) | 6.80 (6.64-6.96) | 6.23 (6.03-6.42) |
| 2016 | 6.12 (5.90-6.34) | 7.06 (6.85-7.28) | 7.21 (7.05-7.37) | 6.57 (6.38-6.77) |
| 2017 | 6.27 (6.06-6.49) | 7.27 (7.05-7.48) | 7.55 (7.38-7.72) | 6.86 (6.66-7.06) |
| 2018 | 6.57 (6.35-6.80) | 7.80 (7.57-8.02) | 7.96 (7.79-8.13) | 7.18 (6.98-7.39) |
| 2019 | 6.85 (6.62-7.08) | 8.11 (7.89-8.34) | 8.73 (8.55-8.91) | 7.28 (7.08-7.49) |
| 2020 | 10.06 (9.78-10.33) | 12.43 (12.15-12.71) | 13.61 (13.39-13.83) | 10.92 (10.67-11.17) |
| Total | 4.37 (4.33-4.41) | 5.02 (4.98-5.06) | 5.47 (5.43-5.50) | 5.19 (5.15-5.22) |
Figure 4. Age-Adjusted Mortality Rates per 100000 Population From 1999 to 2020, Stratified by US Census Region.
Trends are shown for the Northeast (dark blue), Midwest (orange), South (green), and West (light blue).
Non-metropolitan areas (rural areas) consistently had higher obesity- and hypertension-related AAMRs (5.63; 95% CI, 5.58-5.68) than metropolitan areas (urban areas) (4.99; 95% CI, 4.97-5.01). Rural areas also showed the highest increase in AAMR (AAPC: +12.24; 95% CI, 10.60-13.90). Urban areas show an AAPC of +8.53 (95% CI: 6.69-10.40). Notably, rural areas showed a significant, steep increase in AAMR between 1999 and 2001 (APC: 47.95; 95% CI, 26.20-73.45) (Figure 5, Table 3, and Table 9).
Table 9. Age-Adjusted Mortality Rates per 100000 in Obese Individuals With Hypertensive Diseases in the United States According to Urban/Rural Classification (1999-2020).
CI: confidence interval
| Year | Urban (95% CI) | Rural (95% CI) |
| 1999 | 1.10 (1.05-1.15) | 0.99 (0.89-1.09) |
| 2000 | 2.12 (2.05-2.19) | 2.19 (2.05-2.34) |
| 2001 | 2.15 (2.09-2.22) | 2.23 (2.08-2.38) |
| 2002 | 2.49 (2.42-2.56) | 2.76 (2.60-2.93) |
| 2003 | 2.84 (2.77-2.92) | 2.95 (2.78-3.12) |
| 2004 | 2.99 (2.92-3.07) | 3.28 (3.10-3.46) |
| 2005 | 3.19 (3.11-3.27) | 3.70 (3.51-3.89) |
| 2006 | 3.37 (3.29-3.45) | 3.79 (3.60-3.97) |
| 2007 | 3.62 (3.53-3.70) | 3.84 (3.64-4.03) |
| 2008 | 3.84 (3.75-3.92) | 4.39 (4.18-4.59) |
| 2009 | 4.22 (4.13-4.31) | 4.72 (4.51-4.93) |
| 2010 | 4.44 (4.35-4.53) | 4.92 (4.70-5.13) |
| 2011 | 4.87 (4.78-4.96) | 5.52 (5.29-5.75) |
| 2012 | 5.26 (5.17-5.36) | 6.10 (5.86-6.34) |
| 2013 | 5.55 (5.45-5.65) | 6.34 (6.09-6.58) |
| 2014 | 5.94 (5.84-6.04) | 6.99 (6.74-7.25) |
| 2015 | 6.32 (6.22-6.43) | 7.46 (7.20-7.73) |
| 2016 | 6.67 (6.57-6.78) | 7.83 (7.56-8.11) |
| 2017 | 6.88 (6.78-6.99) | 8.33 (8.05-8.61) |
| 2018 | 7.27 (7.16-7.38) | 8.86 (8.57-9.15) |
| 2019 | 7.62 (7.51-7.73) | 9.84 (9.54-10.15) |
| 2020 | 11.75 (11.62-11.89) | 14.23 (13.87-14.59) |
| Total | 4.99 (4.97-5.01) | 5.63 (5.58-5.68) |
Figure 5. Age-Adjusted Mortality Rates per 100000 Population From 1999 to 2020, Stratified by Urbanity.
Trends are shown for urban (purple) and rural (orange) areas.
Estimated excess mortality in 2020
In total, 10508 excess deaths occurred in 2020 (28.09% increase). These data were calculated using the AAPC from 1999 to 2019 to project the expected AAMR for 2020. Women showed 5016 excess deaths (30.95% increase). Men exhibited 5511 excess deaths (25.99% increase). In age groups, the 75+ age group showed the largest increase (2155 excess deaths, 32.62% increase). This was followed by 55-74 (6158 excess deaths, 30.41% increase), 35-54 (2496 excess deaths, 26.43% increase), and 15-34 (242 excess deaths, 21.85% increase). When stratifying by ethnicity and race, Hispanics showed 2447 excess deaths (53.19% increase), which was the highest increase shown by any demographic. Non-Hispanics showed 8223 deaths (25.14% increase). NH Asian or Pacific Islander, NH American Indian, and NH Black or African American all showed similar increases (37.67%, 36.58%, and 35.05%, respectively), with NH Whites showing the lowest percent increase at 25.86%. Furthermore, metro areas showed higher increases (8998 excess deaths, 28.94% increase) than non-metro areas (1680 excess deaths, 25.23% increase), with the South region showing the highest increase (4945 excess deaths, 31.08% increase) (Table 10).
Table 10. Estimated Excess Mortality in Obese Individuals With Hypertensive Diseases in the United States During the COVID-19 Pandemic (2020).
AAPC, average annual percent change; CI, confidence interval; AAMR, age-adjusted mortality rate
| Group | AAPC Until 2019 (95% CI) | Projected AAMR (2019-2020) | Actual AAMR (2020) | Estimated Excess AAMR | Percent Excess AAMR | Estimated Excess Deaths |
| Summary | ||||||
| Overall | 9.84 (8.28-11.42) | 8.73 | 12.14 | 3.41 | 28.09 | 10508 |
| Sex | ||||||
| Male | 10.94 (10.13-11.75) | 10.79 | 14.58 | 3.79 | 25.99 | 5511 |
| Female | 8.34 (6.68-10.02) | 6.76 | 9.79 | 3.03 | 30.95 | 5016 |
| Ethnicity | ||||||
| Hispanic | 7.66 (6.55-8.79) | 5.65 | 12.07 | 6.42 | 53.19 | 2447 |
| Non-Hispanic | 9.87 (8.57-11.19) | 9.14 | 12.21 | 3.07 | 25.14 | 8223 |
| Race | ||||||
| Black or African American | 7.72 (6.30-9.15) | 14.84 | 22.85 | 8.01 | 35.05 | 2916 |
| White | 10.37 (8.53-12.24) | 8.2 | 11.06 | 2.86 | 25.86 | 7243 |
| American Indian | 7.56 (6.35-8.79) | 9.97 | 15.72 | 5.75 | 36.58 | 198 |
| Asian or Pacific Islander | 7.47 (5.92-9.04) | 1.82 | 2.92 | 1.1 | 37.67 | 203 |
| US census region | ||||||
| Northeast | 7.99 (6.95-9.04) | 7.4 | 10.06 | 2.66 | 26.44 | 1462 |
| Midwest | 8.03 (7.37-8.70) | 8.76 | 12.43 | 3.67 | 29.53 | 2407 |
| South | 7.42 (6.78-8.06) | 9.38 | 13.61 | 4.23 | 31.08 | 4945 |
| West | 8.03 (6.36-9.72) | 7.86 | 10.92 | 3.06 | 28.02 | 2190 |
| Metro status | ||||||
| Metro | 9.60 (8.14-11.08) | 8.35 | 11.75 | 3.4 | 28.94 | 8898 |
| Non-metro | 8.15 (7.39-8.92) | 10.64 | 14.23 | 3.59 | 25.23 | 1680 |
| Age group | ||||||
| 15-34 | 11.29 (8.59-14.07) | 0.93 | 1.19 | 0.26 | 21.85 | 242 |
| 35-54 | 9.45 (8.36-10.55) | 8.21 | 11.16 | 2.95 | 26.43 | 2496 |
| 55-74 | 7.02 (6.41-7.64) | 18.81 | 27.03 | 8.22 | 30.41 | 6158 |
| 75+ | 7.64 (7.03-8.24) | 19.44 | 28.85 | 9.41 | 32.62 | 2155 |
Discussion
We conducted a comprehensive analysis of mortality data spanning two decades using the CDC WONDER database to identify cases involving both obesity and hypertension listed as the cause of death. We report several key findings from this investigation. Across all subgroups, AAMR rose steadily from 1999 to 2020, with a more than 11-fold increase over 21 years. Studies from the National Health and Nutrition Examination Survey (NHANES) show that the prevalence of hypertension and obesity during 2017-2020 was 44.7% and 41.9%, respectively [13,14]. Both these conditions have shown an increasing trend over the past two decades. Recent research shows that all-cause mortality was highest in obese individuals with uncontrolled hypertension, followed by those with controlled hypertension and, lastly, those with no hypertension [15].
Overall, men consistently showed a higher mortality rate than women. The 55-74-year-old cohort with obesity and hypertension had the highest risk of mortality as compared to the other age groups. When comparing ethnicities, the non-Hispanic population had higher mortality rates. Notably, non-Hispanic African Americans exhibited the highest mortality rates compared to other racial groups. Significant regional differences were also observed. Rural areas also showed higher AAMRs than urban areas. These results have important public health policy implications.
Our results also show that men have higher mortality rates compared to women. This difference is multifactorial and can be attributed to various factors; estrogen in premenopausal women is protective for cardiovascular health. It enhances endothelial function by increasing nitric oxide production, promotes vasodilation, and inhibits vascular smooth muscle proliferation. It also downregulates angiotensin-converting enzyme and angiotensin II receptors, reducing vasoconstriction and sodium retention, thereby lowering blood pressure and decreasing cardiovascular strain [16,17].
While absolute mortality rates remained substantially higher in the 55-74 age group throughout the study period, the younger age groups (15-34 and 35-54) showed the steepest increases, as indicated by their AAPC values. The observed mortality trends reflect a convergence of epidemiologic and social trends. Since the older adult US population carries a higher burden of obesity and hypertension, they see higher overall cumulative mortality rates [18]. Interestingly, between 1990 and 2021, the age-standardized percentage increase in obesity prevalence was substantially higher among adolescents aged 15-24 years (158.4% in men; 185.9% in women) compared to adults (123.6% in men; 99.9% in women) [19]. In addition to this, we are also seeing rising early-onset hypertension but lower awareness, treatment, and control among young adults aged 18-39 years compared to those ≥40 years [20]. While hypertension becomes more prevalent with advancing age, it remains a largely modifiable condition and is manageable with appropriate interventions. The concurrent and substantial rise in both obesity and hypertension among younger populations presents a more concerning trend. This compounded disease burden across age groups not only intensifies the overall strain on healthcare systems but also contributes to worsening outcomes, particularly among younger individuals who are now developing high-risk cardiometabolic conditions at earlier ages.
Our results showed that AAMRs were higher in non-Hispanic populations than in Hispanic populations. Among non-Hispanic groups, Black individuals exhibited the highest overall AAMRs, a trend consistent with prior research. According to the US National Health and Nutrition Examination Survey, 21% of hypertension cases in Black men and 18% in Black women can be attributed to being overweight. African American women and girls are more overweight and obese than those of other ethnic groups, making them more impacted by this correlation [21]. The increased rates of obesity in African Americans can be linked to the creation of food deserts in the United States, with African Americans being the predominant population. Studies have shown that socioeconomically vulnerable populations have poor access to healthy diets and higher rates of obesity and hypertension worldwide [2,22]. The highest overall increase in AAMR was in the non-Hispanic White population, with the lowest AAPC seen in the non-Hispanic black population. While Black or African American individuals still experience higher obesity rates overall, a study conducted from 1997 to 2008 revealed that BMI rose by 1 kg/m² or more across all race-sex groups. Notably, the White population exhibited a quicker increase during this period [23]. This information is valuable because it shows that several factors, such as sex, education, and socioeconomic status, affect the burden of these comorbidities on the US healthcare system.
Our study highlighted multiple geographic disparities. Of note are the steadily increasing mortality rates in rural areas compared to urban areas. This trend was observed consistently over 21 years. This difference can be attributed to a complex interplay of socioeconomic and behavioral factors unique to rural settings. One of the primary contributors is limited access to healthcare. According to the CDC, rural Americans are more likely to experience preventable hospitalizations and die prematurely from chronic diseases due to a lack of screening and regular follow-ups [24]. Moreover, the built environment in rural areas often promotes obesity. Unlike urban areas, rural communities often have fewer walkable destinations, limited recreational facilities, and less access to fresh food. Consequently, residents may depend on high-calorie, processed options from convenience stores, especially in "food deserts" with few supermarkets [25,26]. Overall, these interwoven factors create a uniquely high-risk environment in rural America, one that promotes obesity and undermines hypertension management, ultimately contributing to the persistent and growing disparity in obesity- and hypertension-related mortality as compared to metropolitan regions. The Northeast census region recorded the highest AAPC but the lowest AAMR, highlighting the critical need for heightened awareness among physicians in this region toward this patient population. Our results essentially signify that factors beyond raw disease prevalence drive rising mortality among people with multiple cardiometabolic conditions in certain areas.
A notable finding from our study was the sharp increase in AAMR for deaths related to obesity and hypertension, which nearly doubled from 1.08 in 1999 to 2.12 in 2000 (Table 2). This steep rise can be attributed to a reporting artifact during those years. In 1999, the United States transitioned from ICD-9 to ICD-10 for recording causes of death on death certificates. Previously, deaths were classified under broader categories such as heart disease or stroke. However, with the adoption of the ICD-10 codes, causes of death began to be recorded more specifically, such as "hypertensive heart disease" or "obesity-related complications." As a result, this sharp increase likely reflects an improved accuracy in capturing obesity- and hypertension-related deaths in the records, rather than a true, sudden doubling of the disease burden.
Our results exhibited a 28% increase in mortality during the early years of the COVID-19 pandemic. Hypertension combined with obesity is a risk factor for mortality from COVID-19, so much so that Perez et al. termed it a "collision of pandemics" [27]. Substantial evidence supports that increasing magnitudes of obesity are associated with an increased risk of mechanical ventilation, which contributes to a drastically increased risk of mortality from COVID-19 [28]. Lockdown protocols in the early pandemic years also proved a double-edged sword, as the limiting of daily physical activities led to a sedentary lifestyle and the increased prevalence of obesity; however, at the same time, obese individuals are at an increased risk of severe COVID-19 infection [29]. Although obesity and hypertension directly increased the risk of mortality in patients with COVID-19, the pandemic also led to a sharp decline in cardiovascular outpatient care, which may have contributed to additional non-COVID-19-related mortality [30].
Our study also showed a disproportionate effect on Hispanic populations, which, compared to non-Hispanic populations, showed double the increase in excess AAMR. This can be attributed to multiple reasons, including limited access to resources, social determinants of health, racism, and discrimination [31]. Addressing these disparities will require multi-level strategies, including expanding healthcare access through public-private partnerships, prioritizing lifestyle-based interventions in underserved communities, and integrating screening for obesity and hypertension into culturally competent primary care frameworks. Furthermore, although rural areas showed higher mortality over the study period, we observed higher percentages of excess AAMR in urban areas than in rural areas in 2020.
Prior studies examining mortality attributable to obesity and hypertension in isolation have reported substantially lower age-adjusted mortality rates than those observed in our cohort. Obesity-related AAMRs in the United States rose from 1.8 to 3.1 per 100000 between 2010 and 2020 [32], while hypertension-related cardiovascular mortality, though accelerating after 2012, remained below the combined rates reported here [33]. This contrast suggests that the co-occurrence of obesity and hypertension confers a mortality burden that exceeds either condition in isolation, underscoring the importance of studying these comorbidities together rather than independently.
Limitations
This study has several limitations inherent to analyses of national death certificate data. First, CDC WONDER relies on the accuracy of death certificate reporting, which may be subject to the misclassification or underreporting of obesity, given that it is often underdiagnosed or omitted in clinical documentation, potentially underestimating the true mortality burden. Second, the dataset's retrospective nature limits our ability to establish causality or to account for temporal relationships among obesity, hypertension, and mortality. Third, we were unable to adjust for individual-level variables such as socioeconomic status, healthcare access, medication use, lifestyle factors, or disease severity; notably, unmeasured confounders, including smoking status and diabetes, may influence the observed associations and should be considered when interpreting demographic disparities. The ICD-10 code E66 does not capture BMI or obesity class, precluding stratification by severity and limiting dose-response assessment. As population-level prevalence data were not incorporated, it is not possible to distinguish whether rising mortality reflects increasing disease prevalence or worsening outcomes among affected individuals. The inclusion of both underlying and contributing causes of death may introduce variability in case definition and could overestimate deaths directly attributable to the combination of both conditions. Finally, changes in coding practices over time, including the ICD-10 transition, may have influenced observed trends. Despite these limitations, the use of a large, nationally representative database provides valuable insight into long-term mortality patterns.
Conclusions
In our retrospective analysis of death certificate data from 1999 to 2020, we found that age-adjusted mortality rates among individuals with both obesity and hypertensive diseases consistently displayed an increasing trend across all demographic groups. The overall rising AAMRs, compounded by the disproportionately high average annual percent changes among White individuals and those aged 15-34, raise serious concerns for the healthcare system. These findings have significant implications for public health policy. Focused interventions are essential to curb the upward trajectory of mortality in this population, as early intervention can greatly help tackle the dual burden of these two largely preventable conditions.
Disclosures
Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. N/A issued approval N/A.
Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:
Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
Author Contributions
Concept and design: Noor Fatima, Ibrahim Zulfiqar Ali, Eemahn Akhtar, Saif Ali Malik
Acquisition, analysis, or interpretation of data: Noor Fatima, Ibrahim Zulfiqar Ali, Talha Khalid, Suleman Khan, Hafsa I. Sair, Maheen Hassan
Drafting of the manuscript: Noor Fatima, Ibrahim Zulfiqar Ali, Talha Khalid, Suleman Khan, Eemahn Akhtar, Hafsa I. Sair, Maheen Hassan, Saif Ali Malik
Critical review of the manuscript for important intellectual content: Noor Fatima, Ibrahim Zulfiqar Ali, Eemahn Akhtar
Supervision: Noor Fatima
References
- 1.Trends and predictions of malnutrition and obesity in 204 countries and territories: an analysis of the Global Burden of Disease Study 2019. Chong B, Jayabaskaran J, Kong G, et al. EClinicalMedicine. 2023;57:101850. doi: 10.1016/j.eclinm.2023.101850. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Has the prevalence of overweight, obesity and central obesity levelled off in the United States? Trends, patterns, disparities, and future projections for the obesity epidemic. Wang Y, Beydoun MA, Min J, Xue H, Kaminsky LA, Cheskin LJ. Int J Epidemiol. 2020;49:810–823. doi: 10.1093/ije/dyz273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Hypertension prevalence among adults aged 18 and over: United States, 2017-2018. Ostchega Y, Fryar CD, Nwankwo T, Nguyen DT. https://stacks.cdc.gov/view/cdc/87559/cdc_87559_DS1.pdf. NCHS Data Brief. 2020:1–8. [PubMed] [Google Scholar]
- 4.Trends in blood pressure control among US adults with hypertension, 1999-2000 to 2017-2018. Muntner P, Hardy ST, Fine LJ, Jaeger BC, Wozniak G, Levitan EB, Colantonio LD. JAMA. 2020;324:1190–1200. doi: 10.1001/jama.2020.14545. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Trends in obesity prevalence among adults with hypertension in the United States, 2001 to 2023. Tu J, Chen H, Zeng Q, Chen L, Guo Y, Chen K. Hypertension. 2025;82:498–508. doi: 10.1161/HYPERTENSIONAHA.124.24123. [DOI] [PubMed] [Google Scholar]
- 6.Diet and lifestyle risk factors associated with incident hypertension in women. Forman JP, Stampfer MJ, Curhan GC. JAMA. 2009;302:401–411. doi: 10.1001/jama.2009.1060. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Hypertension in obesity. Kurukulasuriya LR, Stas S, Lastra G, Manrique C, Sowers JR. Med Clin North Am. 2011;95:903–917. doi: 10.1016/j.mcna.2011.06.004. [DOI] [PubMed] [Google Scholar]
- 8.Influence of perivascular adipose tissue on microcirculation: a link between hypertension and obesity. Agabiti-Rosei C, Saxton SN, De Ciuceis C, Lorenza Muiesan M, Rizzoni D, Agabiti Rosei E, Heagerty AM. Hypertension. 2024;81:24–33. doi: 10.1161/HYPERTENSIONAHA.123.19437. [DOI] [PubMed] [Google Scholar]
- 9.About multiple cause of death, 1999-2020. 2026. https://wonder.cdc.gov/mcd-icd10.html https://wonder.cdc.gov/mcd-icd10.html
- 10.ICD-10-CM. 2024. https://www.cdc.gov/nchs/icd/icd-10-cm/index.html https://www.cdc.gov/nchs/icd/icd-10-cm/index.html
- 11.Race. 2025. https://www.cdc.gov/nchs/hus/sources-definitions/race.html https://www.cdc.gov/nchs/hus/sources-definitions/race.html
- 12.Joinpoint trend analysis software. 2026. https://surveillance.cancer.gov/joinpoint/ https://surveillance.cancer.gov/joinpoint/
- 13.Obesity and severe obesity prevalence in adults: United States, August 2021-August 2023. Emmerich SD, Fryar CD, Stierman B, Ogden CL. https://stacks.cdc.gov/view/cdc/159281/cdc_159281_DS1.pdf. NCHS Data Brief. 2024:1–9. doi: 10.15620/cdc/159281. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Hypertension statistics for US adults: an open-source web application for analysis and visualization of National Health and Nutrition Examination Survey data. Jaeger BC, Chen L, Foti K, et al. Hypertension. 2023;80:1311–1320. doi: 10.1161/HYPERTENSIONAHA.123.20900. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.A two-decade population-based study on the effect of hypertension in the general population with obesity in the United States. Kong G, Chin YH, Lim J, et al. Obesity (Silver Spring) 2023;31:832–840. doi: 10.1002/oby.23658. [DOI] [PubMed] [Google Scholar]
- 16.Estrogen and the vascular endothelium: the unanswered questions. SenthilKumar G, Katunaric B, Bordas-Murphy H, Sarvaideo J, Freed JK. Endocrinology. 2023;164:0. doi: 10.1210/endocr/bqad079. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Estrogen-related mechanisms in sex differences of hypertension and target organ damage. Sabbatini AR, Kararigas G. Biol Sex Differ. 2020;11:31. doi: 10.1186/s13293-020-00306-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.National Health and Nutrition Examination Survey 2017-March 2020 prepandemic data files-development of files and prevalence estimates for selected health outcomes. Stierman B, Afful J, Carroll MD, et al. Natl Health Stat Report. 2021:1–21. doi: 10.15620/cdc:106273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.National-level and state-level prevalence of overweight and obesity among children, adolescents, and adults in the USA, 1990-2021, and forecasts up to 2050. GBD 2021 US Obesity Forecasting Collaborators. http://Epub 2024 Nov 14. PMID: 39551059 PMCID: PMC11694015. Lancet. 2024;404:2278–2298. doi: 10.1016/S0140-6736(24)01548-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Trends in the prevalence, awareness, treatment, and control of hypertension among young adults in the United States, 1999 to 2014. Zhang Y, Moran AE. Hypertension. 2017;70:736–742. doi: 10.1161/HYPERTENSIONAHA.117.09801. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.The association between obesity and hypertension in blacks. Kumanyika SK. Clin Cardiol. 1989;12:0–7. doi: 10.1002/clc.4960121314. [DOI] [PubMed] [Google Scholar]
- 22.Racial differences in perceived food swamp and food desert exposure and disparities in self-reported dietary habits. Cooksey Stowers K, Jiang Q, Atoloye A, Lucan S, Gans K. Int J Environ Res Public Health. 2020;17:7143. doi: 10.3390/ijerph17197143. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Black-white disparities in overweight and obesity trends by educational attainment in the United States, 1997-2008. Jackson CL, Szklo M, Yeh HC, Wang NY, Dray-Spira R, Thorpe R, Brancati FL. J Obes. 2013;2013:140743. doi: 10.1155/2013/140743. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Preventing chronic diseases and promoting health in rural communities. 2024. https://www.cdc.gov/health-equity-chronic-disease/health-equity-rural-communities/index.html https://www.cdc.gov/health-equity-chronic-disease/health-equity-rural-communities/index.html
- 25.Use of deep learning to examine the association of the built environment with prevalence of neighborhood adult obesity. Maharana A, Nsoesie EO. JAMA Netw Open. 2018;1:0. doi: 10.1001/jamanetworkopen.2018.1535. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Differences in the influence of the built environment and physical activity on obesity in urban and suburban contexts. Zou Y, Wang D. Soc Sci Med. 2025;372:117955. doi: 10.1016/j.socscimed.2025.117955. [DOI] [PubMed] [Google Scholar]
- 27.Hypertension, obesity, and COVID-19: a collision of pandemics. Perez A, Naljayan M, Shuja I, Florea A, Reisin E. Curr Hypertens Rep. 2021;23:36. doi: 10.1007/s11906-021-01153-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Association of body mass index and age with morbidity and mortality in patients hospitalized with COVID-19: results from the American Heart Association COVID-19 Cardiovascular Disease Registry. Hendren NS, de Lemos JA, Ayers C, et al. Circulation. 2021;143:135–144. doi: 10.1161/CIRCULATIONAHA.120.051936. [DOI] [PubMed] [Google Scholar]
- 29.Individuals with obesity and COVID-19: a global perspective on the epidemiology and biological relationships. Popkin BM, Du S, Green WD, et al. Obes Rev. 2020;21:0. doi: 10.1111/obr.13128. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.The collateral damage of COVID-19 to cardiovascular services: a meta-analysis. Nadarajah R, Wu J, Hurdus B, et al. Eur Heart J. 2022;43:3164–3178. doi: 10.1093/eurheartj/ehac227. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Hispanic ethnicity and mortality among critically ill patients with COVID-19. Ricardo AC, Chen J, Toth-Manikowski SM, et al. PLoS One. 2022;17:0. doi: 10.1371/journal.pone.0268022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Trends and patterns in obesity-related deaths in the US (2010-2020): a comprehensive analysis using Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) data. Achara KE, Iyayi IR, Erinne OC, et al. Cureus. 2024;16:0. doi: 10.7759/cureus.68376. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Trends in hypertension-related cardiovascular mortality in the United States, 2000 to 2018. Rethy L, Shah NS, Paparello JJ, Lloyd-Jones DM, Khan SS. Hypertension. 2020;76:0–5. doi: 10.1161/HYPERTENSIONAHA.120.15153. [DOI] [PMC free article] [PubMed] [Google Scholar]