SYNOPSIS Despite growing recognition of the problem, the obesity epidemic continues in the U.S., and obesity rates are increasing around the world. The latest estimates are that approximately 34% of adults and 15–20% of children and adolescents in the U.S. are obese. Obesity affects every segment of the U.S. population. Obesity increases the risk of many chronic diseases in children and adults. The epidemic of obesity arose gradually over time, apparently from a small, consistent degree of positive energy balance. Substantial public health efforts are being directed toward addressing obesity, but there is not yet clear evidence of success. Because of the complexity of obesity, it is likely to be one of the most difficult public health issues our society has faced.

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High blood pressure (BP) is the leading cause of worldwide cardiovascular disease morbidity and mortality. Patients and clinicians dealing with hypertension have benefited from the evidence of event-based randomized controlled clinical trials. One result from those trials has been the development of evidence-based guidelines. The commitment to using evidence from these event-based randomized trials has been a cornerstone in the development of guideline treatment recommendations. However, in some situations, evidence from event-based trials is not available to guideline writers or clinicians for assistance in treatment decision making. Such is the case for the management of many patients with stage 1 hypertension. The purpose of this scientific statement is to provide information complementary to the 2017 Hypertension Clinical Practice Guidelines for the patient with untreated stage 1 hypertension (systolic BP/diastolic BP, 130–139/80–89 mm Hg) with a 10-year risk for atherosclerotic cardiovascular disease <10% who fails to meet the systolic BP/diastolic goal (<130/80 mm Hg) after 6 months of guideline-recommended lifestyle therapy. This statement provides evidence from sources other than event-based randomized controlled clinical trials and offers therapy options for consideration by clinicians.

Observational studies suggest outpatient metformin use is associated with reduced mortality from coronavirus disease‐2019 (COVID‐19). Metformin is known to decrease interleukin‐6 and tumor‐necrosis factor‐α, which appear to contribute to morbidity in COVID‐19. We sought to understand whether outpatient metformin use was associated with reduced odds of severe COVID‐19 disease in a large US healthcare data set. Retrospective cohort analysis of electronic health record (EHR) data that was pooled across multiple EHR systems from 12 hospitals and 60 primary care clinics in the Midwest between March 4, 2020 and December 4, 2020. Inclusion criteria: data for body mass index (BMI) > 25 kg/m 2 and a positive SARS‐CoV‐2 polymerase chain reaction test; age ≥ 30 and ≤85 years. Exclusion criteria: patient opt‐out of research. Metformin is the exposure of interest, and death, admission, and intensive care unit admission are the outcomes of interest. Metformin was associated with a decrease in mortality from COVID‐19, OR 0.32 (0.15, 0.66; p = .002), and in the propensity‐matched cohorts, OR 0.38 (0.16, 0.91; p = .030). Metformin was associated with a nonsignificant decrease in hospital admission for COVID‐19 in the overall cohort, OR 0.78 (0.58–1.04, p = .087). Among the subgroup with a hemoglobin HbA1c available ( n = 1193), the adjusted odds of hospitalization (including adjustment for HbA1c) for metformin users was OR 0.75 (0.53–1.06, p = .105). Outpatient metformin use was associated with lower mortality and a trend towards decreased admission for COVID‐19. Given metformin's low cost, established safety, and the mounting evidence of reduced severity of COVID‐19 disease, metformin should be prospectively assessed for outpatient treatment of COVID‐19.

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