For decades, obesity has been closely tied to higher blood pressure and less healthy cholesterol levels, two major markers of cardiovascular risk. But a large new analysis suggests that picture has changed for many adults over 40 in several high-income countries, including the United States and England.
The study, published in The Lancet, found that blood pressure and non-HDL cholesterol levels among middle-aged and older adults with obesity have become increasingly similar to, and in some cases healthier than, those seen in adults with a normal BMI. The researchers say the shift is likely tied to wider use of blood pressure and cholesterol-lowering medications, rather than obesity becoming harmless. The findings also do not erase other risks linked to obesity, including type 2 diabetes, kidney disease, liver disease and some cancers.
The observational study analyzed blood pressure and cholesterol data from 110 health datasets, including nearly 1 million participants from 1990 to 2024. The data came from seven high-income countries: England, the United States, Japan, South Korea, Taiwan, Thailand and Finland. Researchers compared adults with obesity, overweight and normal BMI.
In the 1990s, adults with obesity generally had higher blood pressure and higher levels of non-HDL cholesterol, sometimes called “unhealthy” cholesterol, than adults with normal BMI. Non-HDL cholesterol includes cholesterol carried by LDL, VLDL and other particles linked to plaque buildup in blood vessels.
Over time, those gaps narrowed in most of the countries studied. The pattern was especially clear among adults ages 40 to 79, and most striking among adults ages 60 to 79. In England and the United States, older adults with obesity, particularly those with severe obesity, had similar or even lower blood pressure and non-HDL cholesterol levels by the end of the study period compared with older adults with normal BMI.
The researchers point to medication as the likely explanation. Over the past three decades, adults with obesity have become more likely than adults with normal BMI to use cholesterol-lowering medications, such as statins, and blood pressure medications. Among older men with severe obesity in England and the United States, about 70% to 72% were taking cholesterol-lowering medication by the early 2020s, compared with 40% to 48% of older men with normal BMI.
“This latest analysis suggests that the observed convergence in cholesterol and blood pressure levels between people aged over 40 with obesity and those with a normal BMI is largely due to statins and other widely accessible medications to reduce cardiovascular risk,” said Lakshya Jain, from the School of Public Health at Imperial College London. “That is a significant public health success story, and one we should not lose sight of as new weight-loss medications enter the picture.”
That success story has limits. The study looked at blood pressure and cholesterol, not actual rates of heart attack, stroke, heart failure or death. It also cannot prove that medication caused the convergence, though the timing and pattern support that explanation.
The findings were also not the same for younger adults. Among adults under 40, the study found little or no narrowing in the blood pressure and cholesterol gaps between those with obesity and those with normal BMI. The researchers noted that younger adults are much less likely to receive cholesterol-lowering or blood pressure medications, regardless of BMI.
"While good news for older adults with obesity, our results suggest that cardiovascular health risks remain higher for adults under 40 than for their counterparts with a normal BMI,” said Ysé d'Ailhaud de Brisis, from the School of Public Health at Imperial College London.
That does not mean younger adults with obesity should automatically be treated with medication. But the authors said earlier screening, lifestyle support and medication when appropriate may help prevent long-term cardiovascular complications.
The study also arrives as weight-loss medications are becoming more widely used. The researchers said their findings offer a snapshot of the cardiovascular health of adults who may be likely to receive those medications, while showing that existing treatments for blood pressure and cholesterol have already changed part of the obesity risk picture.
Still, the study should not be read as evidence that BMI no longer matters, or that managing blood pressure and cholesterol addresses every health concern linked to obesity. In a linked comment, Dr. Yuan Lu of Yale School of Medicine, who was not involved in the study, wrote that the findings show obesity-related cardiovascular risk reflects not only excess body fat, but also access to treatment, health system engagement and the timing of intervention.
“Convergence of risk factors should not be equated with elimination of obesity-related risk,” Lu wrote.
The researchers also noted that the findings may not apply outside the countries studied, especially in low- and middle-income countries where access to cholesterol and blood pressure medications may be lower. They also could not assess the impact of different medication doses.
This study was funded by the UK Medical Research Council. Analysis of obesity data in Europe was also supported by UK Research and Innovation through participation in the OBCT consortium.
Several authors reported financial relationships outside the submitted work. These included research grants, consulting fees, advisory board payments or speaking payments from pharmaceutical and health-related companies, including companies involved in cardiometabolic care, diabetes, obesity treatment and related areas.