Pub Date: Monday, Sep 20, 2021
Author: Alvin Chandra, MD, FACC
Affiliation: Division of Cardiology, University of Texas Southwestern Medical Center
According to a report from the World Health Organization (WHO), approximately 1.1 billion people worldwide have hypertension with prevalence of 1 in 4 men and 1 in 5 women.1 Notably, one of WHO’s global targets is to reduce hypertension by 25% between 2010 and 2025. In the United States (U.S.), the prevalence is higher with 45% of adults having hypertension.2 The absolute burden in the U.S. has also increased from 87 million adults in 1999-2000 to 108 million in 2015-2016.3 Hypertension prevalence also increases with age with 54.5% prevalence in adults aged 40–59 and 74.5% in adults aged 60 and over. In 2018 alone, hypertension was a contributor to nearly half a million deaths in the United States.4
Association between obesity and hypertension have been well described.5 Data from population-based studies showed nearly linear relationship between body mass index (BMI) and blood pressure.6,7 Findings from the Framingham Heart Study showed that 78% of essential (primary) hypertension in men and 65% in women can be attributed to obesity.8 Unfortunately, worldwide prevalence of obesity has almost tripled since 1975 according to a WHO report. In 2016, >1.9 billion adults (39%) were classified as overweight, and among those >650 million (13%) were obese.9 In the U.S., the prevalence of obesity is even higher with 42% of adults classified as obese in 2017-2018, an increase from 30% in 1999-2000.10 Given the strong association between obesity and hypertension, we should expect a continued rise of hypertension prevalence in the United States and the world in the future.
Association between obesity and hypertension is at least partially mediated by fat depot distribution. Increased deposition of visceral fat is associated with increased risk of hypertension compared to other fat depots, including subcutaneous and lower body fat.11,12,13 Aerobic exercise has been shown to reduce visceral adiposity.14 Similarly, combination of endurance and strength training has also been shown to decrease visceral fat while increasing muscle mass.15 However, to this date, no large study has been performed to link this reduction of visceral adiposity by exercise and its association with improvement/prevention of hypertension. Among drugs approved by the Food and Drug Administration (FDA) for weight loss, orlistat has been shown to have the greatest reduction in visceral fat, with a mean reduction of 67 cm2.16 As mentioned in the Statement, orlistat, which reduces intestinal fat absorption, was associated with 3% decrease in body weight and decline in blood pressure which could be mediated by reduction in visceral adiposity. Liraglutide, a centrally acting drug which increases satiety, also demonstrated reductions in body weight, blood pressure, and visceral fat.17,18 Interestingly, while its weight loss effect has not been described, combination of empagliflozin and metformin have been shown to reduce visceral fat as well.16,18 Future clinical trials are needed to create more approaches that treat and prevent hypertension by targeting visceral adiposity.
In addition to the medications mentioned previously, many other drugs have been approved by the FDA for weight loss: phentermine, diethylproprion, phendimetrazine, and benzphetamine for short-term use; phentermine/topiramate extended release, and naltrexone/bupropion for long-term use. Despite these options, only around 1% of eligible patients were prescribed weight loss pharmacotherapy in the U.S.,19,20 which is an abysmally low prescription rate of a treatment of a disease that is ravaging the country and the world. Additionally, 24% of prescribing providers account for 90% of filled prescriptions. While these drugs are not strikingly effective and certainly are not free of adverse effects, even a slight increase of prescription rate would likely have a non-trivial effect on the prevalence of obesity and hypertension in the U.S. and the world. Metabolic surgery appears to be a more effective approach in reducing obesity and hypertension. Systematic reviews of observational data and The Gastric Bypass to Treat Obese Patients with Steady Hypertension (GATEWAY) trial showed that metabolic surgery was superior to medical therapy in controlling blood pressure and reducing weight with a relatively durable result.21,22 With improvement in surgical techniques, the contemporary complication rate of metabolic surgery is similar to routine surgeries such as laparoscopic cholecystectomy or appendectomy.23 Yet, similar to drugs, in 2017 only approximately 1 percent of eligible patients underwent metabolic surgery.24 Future studies are needed to definitively determine long-term safety and efficacy of these approaches and to further elucidate factors influencing the beliefs of patients and healthcare providers regarding these approaches. Public health campaign would likely be needed in the future as well.
Lifestyle interventions which include exercise, physical activity, and dietary modification are effective strategies in reducing body weight and blood pressure as described in the Scientific Statement. While they should always be an integral part of weight loss strategy given its lack of significant adverse effects and low cost, lifestyle interventions are subject to recidivism which significantly reduce the beneficial effects of weight-loss on blood pressure over time, and much of it is related to weight regain.25 Weight-loss maintenance requires high levels of physical activity and continued dietary modification.26 There are public health interventions that can “nudge” an individual’s physical activity level by strategic planning and zoning of public spaces which could limit traffic to make walking and cycling safer, improving public transportation, or building schools and shops within walking distance of neighborhoods.27, 28 Just as importantly, we need to increase our effort in preventing and reducing childhood obesity. A systematic review and meta-analysis found that school-based interventions are effective in preventing childhood obesity.29 A renewal and reinforcement of programs like “Let’s Move!” that was led by former First Lady, Michelle Obama, can help this critical goal of decreasing childhood obesity.30 This Scientific Statement provides a timely and comprehensive review of identifying the mechanisms obesity-related hypertension and describing current and future strategies of prevention and treatment of obesity and hypertension.
Hall ME, Cohen JB, Ard JD, Egan BM, Hall JE, Lavie CJ, Ma J, Ndumele CE, Schauer PR, Shimbo D; on behalf of the American Heart Association Council on Hypertension; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Lifestyle and Cardiometabolic Health; and Stroke Council. Weight loss strategies for prevention and treatment of hypertension: a scientific statement from the American Heart Association [published online ahead of print September 20, 2021]. Hypertension. doi: 10.1161/HYP.0000000000000202
- “Fact Sheet: Hypertension.” World Health Organization, World Health Organization, https://www.who.int/news-room/fact-sheets/detail/hypertension. Accessed 17 Jul, 2021.
- Centers for Disease Control and Prevention (CDC). Hypertension Cascade: Hypertension Prevalence, Treatment and Control Estimates Among US Adults Aged 18 Years and Older Applying the Criteria From the American College of Cardiology and American Heart Association’s 2017 Hypertension Guideline—NHANES 2013–2016. Atlanta, GA: US Department of Health and Human Services; 2019.
- Dorans KS, Mills KT, Liu Y, He J. Trends in Prevalence and Control of Hypertension According to the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline. J Am Heart Assoc. 2018;7(11):e008888. Published 2018 Jun 1. doi:10.1161/JAHA.118.008888
- Centers for Disease Control and Prevention. Underlying Cause of Death, 1999–2018. CDC WONDER Online Database. Atlanta, GA: Centers for Disease Control and Prevention; 2018. http://wonder.cdc.gov/ucd-icd10.html. Accessed 17 Jul, 2020.
- DeMarco VG, Aroor AR, Sowers JR. The pathophysiology of hypertension in patients with obesity. Nat Rev Endocrinol. 2014;10(6):364-376. doi:10.1038/nrendo.2014.44
- Hall JE. The kidney, hypertension, and obesity. Hypertension. 2003;41(3 Pt 2):625-633. doi:10.1161/01.HYP.0000052314.95497.78
- Jones DW, Kim JS, Andrew ME, Kim SJ, Hong YP. Body mass index and blood pressure in Korean men and women: the Korean National Blood Pressure Survey. J Hypertens. 1994; 12:1433–1437.
- Garrison RJ, Kannel WB, Stokes J 3rd, Castelli WP. Incidence and precursors of hypertension in young adults: the Framingham Offspring Study. Prev Med. 1987;16(2):235-251. doi:10.1016/0091-7435(87)90087-9
- “Fact Sheet: Obesity and Overweight.” World Health Organization, World Health Organization, https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight. Accessed 17 Jul, 2021.
- Centers for Disease Control and Prevention (CDC). NCHS, National Health and Nutrition Examination Survey, 1999–2018.
- Chandra A, Neeland IJ, Berry JD, et al. The relationship of body mass and fat distribution with incident hypertension: observations from the dallas heart study. J Am Coll Cardiol. 2014;64:997-1002.
- Alvarez GE, Beske SD, Ballard TP and Davy KP. Sympathetic neural activation in visceral obesity. Circulation. 2002;106:2533-2536.
- Piche ME, Tchernof A and Despres JP. Obesity Phenotypes, Diabetes, and Cardiovascular Diseases. Circ Res. 2020;126:1477-1500.
- Keating SE, Hackett DA, Parker HM, et al. Effect of aerobic exercise training dose on liver fat and visceral adiposity. J Hepatol.2015;63(1):174-182. doi:10.1016/j.jhep.2015.02.022
- Park SK, Park JH, Kwon YC, Kim HS, Yoon MS, Park HT. The effect of combined aerobic and resistance exercise training on abdominal fat in obese middle-aged women. J Physiol Anthropol Appl Human Sci. 2003;22(3):129-135. doi:10.2114/jpa.22.129
- Rao S, Pandey A, Garg S, et al. Effect of Exercise and Pharmacological Interventions on Visceral Adiposity: A Systematic Review and Meta-analysis of Long-term Randomized Controlled Trials. Mayo Clin Proc. 2019;94(2):211-224. doi:10.1016/j.mayocp.2018.09.019
- Cohen JB and Gadde KM. Weight Loss Medications in the Treatment of Obesity and Hypertension. Curr Hypertens Rep. 2019;21:16.
- Ruiz JR, Lavie CJ, Ortega FB. Exercise versus pharmacological interventions for reducing visceral adiposity and improving health outcomes. Mayo Clin Proc. 2019 ;94(2):182-185.
- Zhang S, Manne S, Lin J and Yang J. Characteristics of patients potentially eligible for pharmacotherapy for weight loss in primary care practice in the United States. Obes Sci Pract. 2016;2:104-114.
- Saxon DR, Iwamoto SJ, Mettenbrink CJ, et al. Antiobesity Medication Use in 2.2 Million Adults Across Eight Large Health Care Organizations: 2009-2015. Obesity (Silver Spring). 2019;27(12):1975-1981. doi:10.1002/oby.22581
- Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K and Schoelles K. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-37.
- Schiavon CA, Bersch-Ferreira AC, Santucci EV, et al. Effects of Bariatric Surgery in Obese Patients With Hypertension: The GATEWAY Randomized Trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension) [published correction appears in Circulation. 2019 Oct;140(14):e718]. Circulation. 2018;137(11):1132-1142. doi:10.1161/CIRCULATIONAHA.117.032130
- Aminian A, Brethauer SA, Kirwan JP, Kashyap SR, Burguera B and Schauer PR. How safe is metabolic/diabetes surgery? Diabetes Obes Metab. 2015;17:198-201.
- “New Study Finds Most Bariatric Surgeries Performed in Northeast, and Fewest in South Where Obesity Rates are Highest, and Economies are Weakest.” American Society for Metabolic and Bariatric Surgery, https://asmbs.org/articles/new-study-finds-most-bariatric-surgeries-performed-in-northeast-and-fewest-in-south-where-obesity-rates-are-highest-and-economies-are-weakest. Accessed 18 Jul, 2021.
- Semlitsch T, Jeitler K, Berghold A, Horvath K, Posch N, Poggenburg S and Siebenhofer A. Long-term effects of weight-reducing diets in people with hypertension. Cochrane Database Syst Rev. 2016;3:CD008274.
- Wing RR and Phelan S. Long-term weight loss maintenance. Am J Clin Nutr. 2005;82:222S-225S.
- Sallis JF, Glanz K. Physical activity and food environments: solutions to the obesity epidemic. Milbank Q. 2009; 87:123-54.
- Khan LK, Sobush K, Keener D, et al. Recommended community strategies and measurements to prevent obesity in the United States. MMWR Recomm Rep. 2009; 58:1-26.
- Wang Y, Cai L, Wu Y, et al. What childhood obesity prevention programmes work? A systematic review and meta-analysis. Obes Rev. 2015;16(7):547-565. doi:10.1111/obr.12277
- Katz DL. Let's Move! Progress, promise, and the miles left to go. Child Obes. 2012;8(1):2-3. doi:10.1089/chi.2011.0800.katz
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-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --