Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Hypertension

4,575 views

Published on

management of hypertension

Published in: Science
  • Hello! Get Your Professional Job-Winning Resume Here - Check our website! https://vk.cc/818RFv
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Hypertension

  1. 1. patient with hyperte nsion Nursing management of patient with hypertension
  2. 2. Blood pressure  In normal circulation, pressure is exerted by the flow of blood through the heart and blood vessels. It is the product of cardiac output multiplied by peripheral resistance. Normal blood pressure at rest is within the range of 100-140mmHg systolic (top reading) and 60- 90mmHg diastolic .
  3. 3. Determinants of BP and regulation  These are the fundamental factors which determine the value of BP. They are  1. Cardiac output  2.peripheral vascular resistance These are also called as factors controlling BP.  BP= cardiac output X PVR
  4. 4. Regulatory mechanisms  Short term: Short term regulations are achieved by neural regulations where as long term regulations are achieved by controlling blood volume and Na retension via renal mechanisms.  Nervous System Control :BP by changing blood distribution in the body and by changing blood vessel diameter. Sympathetic & Parasympathetic activity will affects veins, arteries & heart to control HR and force of contraction
  5. 5.  Baroreceptors :Baroreceptors are stretch receptors found in the carotid body, aortic body and the wall of all large arteries of the neck and thorax. Baroreceptors entered the medululla Secondary signals inhibit the vasoconstrictor center of medulla and excite the vagal parasympathetic center effect vasodilatation of the veins and arterioles decreased heart rate and strength of heart contractiont herefore, causes arterial pressure to decrease (as decrease in PR and CO) Conversely, low pressure has opposite effects,reflexly causing the pressure rise back to normal
  6. 6.  Increased Parasympathetic Activity: Effect of increased parasympathetic and decreased sympathetic activity on heart and blood pressure: Increased activity of vagus (parasympathetic) nerve .  Decreased activity of sympathetic cardiac Nerves Reduction of heart rate .Lower cardiac output .Lower blood pressure
  7. 7. Long term  long term control is achieved by adjusting the blood volume and lowering Ca concentration in the VSM.  Hormones :1)ADH reduces water excreation and causes water conservation.2) Renin ultimately cause production of angiotensin II causes aldosterone production which leads to the water and sodium retension.  ANP:released when atria are stretched . it causes dieresis and reduce blood volume and BP.  .
  8. 8.  Role of Ca ions in the VSM : Its accumulation causes rise in the vascular tone and increases the vascular tone  Endocrine system: stimulation of SNS results in release of epinephrine along with small fraction of nor epinephrine by adrenal medulla. epinephrine increases CO by increasing HR and myocardial contractility
  9. 9. Factors affecting BP  A. PHYSIOLOGICAL  Age :tends to increase in elder people.  Sex:before the onset of menopause women have little lower BP than that of males of same age group.after menopause women have little higher BP than that of males.  Meals: after meals BP is higher.  Emotion: range and panic may rise BP.  Exposure to cold : increase BP.inorder to preserve body heat,body tries to keep temperature by Cutaneous vaso constriction as a result of SNS stimulation.  Excercise  Sleep:cause fall of BP.  Circardian rhythm: BPis highest in the morning and least in the night.
  10. 10.  B. PATHOLOGICAL  Clinical conditions alter BP include renal artery senosis, pheochromacytoma and pre eclampsia  Drug induced: sympathetic stimulants like adrenalin,nor adrenalin, andphenylephrine rise BP, while vascular smooth muscle relaxants like hydralazine reduces BP.
  11. 11. Hypertension- definition  Hypertension is defined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) as a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg based on the average of two or more accurate blood pressure measurements taken during two or more contacts with a health care provider.
  12. 12. Hypertension- definition  Hypertension is defined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) as a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg based on the average of two or more accurate blood pressure measurements taken during two or more contacts with a health care provider.
  13. 13.  World hypertension day: May 17  The theme for World Hypertension Day 2013 is “Healthy Heart Beat - Healthy Blood Pressure”.
  14. 14. Global incidence  As per the World Health Statistics 2012, of the estimated 57 million global deaths in 2008, 36 million (63%) were due to noncommunicable diseases (NCDs). The largest proportion of NCD deaths is caused by cardiovascular diseases (48%). In terms of attributable deaths, raised blood pressure is one of the leading behavioral and physiological risk factor to which 13% of global deaths are attributed. Hypertension is reported to be the fourth contributor to premature death in developed countries and the seventh in developing countries.
  15. 15. National prevalence  The prevalence of hypertension in the last six decades has increased from 2% to 25% among urban residents and from2% to 15% among the rural residents in India. According to Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, the overall prevalence of hypertension in India by 2020 will be159.46/1000 population
  16. 16. Classification  Blood pressure(mmhg) Classsification Systolic Diastolic Normal 119 or lower 79 or lower Prehypertension 120-139 80-89 Stage1 hypertenson 140-159 90-99 Stage2 hypertension 160 0r higher 100 or higher
  17. 17. Causes  In general the major causes of hypertension are the following:  Hectic and stress filled life style  Unhealthy food habits  Obesity  Excessive consumption of liquors  Smoking  Over consumption of tea/coffee  Insufficient rest and sleep  Metabolic disorders
  18. 18. Contd……  Hardening of the arteries  Excessive use of pain killers and other strong medicines  Genetic disorders  Over consumption of oily food and fast food  High salt intake  Emotional and Physical stress  Family history of hypertension
  19. 19. Secondary causes  Sleep apnoea  Drug-induced or drug-related  Chronic kidney disease  Primary aldosteronism  Renovascular disease  Chronic steroid therapy and Cushing syndrome  Phaeochromocytoma  Acromegaly  Thyroid or parathyroid disease  Coarctation of the aorta  Takayasu Arteritis 
  20. 20. Primary hypertension  Primary (essential) hypertension is the most common form of hypertension, accounting for 90–95% of all cases of hypertension. Insulin resistance, which is common in obesity and is a component of syndrome X (or the metabolic syndrome), is also thought to contribute to hypertension
  21. 21. Risk factors for primary hypertension  Age: SBP increase progressively with increasing age. After 50, an SBP>140 mmHg is a more important risk factor for CAD than DBP.  Alcohol:  Cigarette smoking:increase the risk of CVD.  Diabetes mellitus: hypertension is more common in diabetes mellitus.  Elevated serum lipids: primary risk factor for atherosclerosis.  Excess dietary sodium:contribute to hypertension.  Gender:Hypertension more prevalent in young adulthood. After55yr,more prevalent in women.  .
  22. 22.  Family history:  Obesity  Ethnicity: Twice as high in African Americans than that of whites.  Sedentary life style: Regular physical activity reduce obesity and decrease BP.  Socio economic status: more prevalent in people with low socio economic status.  Stress: Increase the incidence of hypertension
  23. 23. Secondary hypertension  Secondary hypertension results from an identifiable cause. Renal disease is the most common secondary cause of hypertension. Hypertension can also be caused by endocrine conditions, such as Cushing's syndrome, hyperthyroidism, hypothyroidism, acromegaly, Conn's syndrome or hyperaldosteronism, hyperparathyroidism and pheochromocytoma.
  24. 24. Cause of Secondary Hypertension Diagnostic Tests Management Renovascular disease Renal duplex ultrasonography, CT or MR angiography, renal angiogram. Balloon angioplasty in patients with FMD; medical management with ACE inhibitor or ARB in combination with a diuretic for patients with atherosclerotic renal artery disease. Primary aldosteronism Plasma aldosterone renin ratio, salt loading test for confirmation, CT scan of adrenal and adrenal vein sampling for localization. In a patient with adrenal hyperplasia or bilateral functional adrenal adenoma, medical therapy with aldosterone antagonist. In a patient with unilateral functional adenoma, adrenalectomy of the affected adrenal gland. Cushing syndrome Dexamethasone suppression test, salivary cortisol levels, CT adrenal gland. Treat primary cause for excess cortisol levels. Pheochromocytoma Plasma metanephrines, 24-hour urinary metanephrines and catecholamines, CT, MRI, metaiodobenzylguanidine scan if CT or MRI are not conclusive. Adrenalectomy of the affected adrenal gland. Coarctation of aorta Echocardiogram, MR angiography, aortogram. Angioplasty or surgical correction. Renovascular disease Renal duplex ultrasonography, CT or MR angiography, renal angiogram. Balloon angioplasty in patient with FMD; medical management with ACE inhibitor or ARB in combination with a diuretic for patient with atherosclerotic renal artery disease.
  25. 25. Essential hypertension or idiopathic hypertension  It is the most common form of hypertension, which occurs in almost 90 percent of cases. The causes of essential hyper tension is unknown, however, medical studies and research have identified some factors which cause hypertension. Some of these factors are unhealthy dietary habits, tension, stress, insufficient rest, smoking, excessive consumption of liquors, obesity, metabolic disorders, excessive consumption of tea and coffee etc
  26. 26. Hypertensive crisis  Hypertensive crisis broadly covers both hypertensive urgency and emergency. JNC 7 defines hypertensive emergency as severe elevation in BP (>180/120 mmHg) complicated by evidence of impending or progressive target organ dysfunction and damage.When severe elevation in BP occurs without acute target organ dysfunction or damage, it is defined as hypertensive urgency
  27. 27. Hypertensive emergency  previously "malignant hypertension", is diagnosed when there is evidence of direct damage to one or more organs as a result of the severely elevated blood pressure. This may include hypertensive encephalopathy, altered level of consciousness ,Retinal papilloedema ,Chest pain ,myocardial infarction) ,aortic dissection, , signs of pulmonary edema,deterioration of kidney function may occur.
  28. 28. Resistant hypertension  Resistant hypertension is defined as hypertension that remains above goal blood pressure in spite of concurrent use of three antihypertensive agents belonging to different antihypertensive drug classes
  29. 29. Hypertensive crisis  Severely elevated blood pressure (equal to or greater than a systolic 180 or diastolic of 110 — sometime termed malignant or accelerated hypertension) is referred to as a "hypertensive crisis.People with blood pressures in this range may have no symptoms, but are more likely to report headaches (22% of cases) and dizziness than the general population.Other symptoms accompanying a hypertensive crisis may include visual deterioration or breathlessness due to heart failure or a general feeling of malaise due to renal failure.
  30. 30. Pathophysiology Etiological factors  sed periphral resistance   sed venous compliance sed venous return  cardiac preload  Diastolic dysfunction
  31. 31. Signs and symptoms.  Headaches - Headaches may be experienced due to elevation in blood pressure. Sometimes morning headaches can also be due to hypertension.  Dizziness - Dizziness is often experience by people with high blood pressure. However dizziness cannot always be treated as a symptom of hypertension. If dizziness is experienced it is always wise to consult a medical practitioner.  Heart pain  Palpitations  Nosebleeds - Nosebleeds without particular reason might be a symptom of high blood pressure. It is better to check the blood pressure in such cases.  Difficulty in breathing  Tinnitus (ringing or buzzing in the ears)  Blurred Vision  Frequent urination
  32. 32. Diagnosis  History and physical examination  24-hour ambulatory blood pressure monitors and home blood pressure monitoring  Patterns of Blood Pressure  Based on 24-hour ambulatory BP monitoring and office BP readings, 4 patterns of BP have been described  sustained hypertension, Masked hypertension white coat hypertension , normal dipping pattern
  33. 33. Home Blood Pressure Monitoring  Home BP measurement guidelines recommend that a validated device be used to measure BP at home Blood pressure measurements using such validated devices should be taken before an office visit, with at least 2 morning and 2 evening readings everyday for 1 week (but discarding the readings of the first day), which gives a total of 12 BP readings over a week, based on which clinical decisions can be made. Hypertension is defined as a mean home blood pressure of ≥135/85 mmHg. Home blood pressure monitoring provides an inexpensive alternative to 24-hour ambulatory BP monitoring.
  34. 34.  The recently released National Institute of Health and Clinical Excellence (NICE) guidelines published in the United Kingdom recommend that a diagnosis of primary hypertension should be confirmed with 24- hour ambulatory blood pressure monitoring or home blood pressure monitoring rather than by relying solely on office blood pressure measurement.
  35. 35. laboratoryTests  Renal  Microscopic urinalysis, proteinuria, BUN and/or creatinine   Endocrine  Serum sodium, potassium, calcium, TSH   Metabolic  Fasting blood glucose, HDL, LDL, and total cholesterol, triglycerides
  36. 36. Others Electrocardiogram Echo cardiography On physical examination, hypertension may be suspected on the basis of the presence of hypertensive retinopathy detected by examination of the optic fundus found in the back of the eye using ophthalmoscopy
  37. 37. Prevention  Maintain normal body weight for adults (e.g. body mass index 20–25 kg/m2)  Reduce dietary sodium intake to <100 mmol/ day (<6 g of sodium chloride or <2.4 g of sodium per day)  Engage in regular aerobic physical activity such as brisk walking (≥30 min per day, most days of the week)  Limit alcohol consumption to no more than 3 units/day in men and no more than 2 units/day in women  Consume a diet rich in fruit and vegetables (e.g. at least five portions per day);  Effective lifestyle modification may lower blood pressure
  38. 38. Management of Hypertension Goals of Therapy  The primary goal of therapy of hypertension should be effective control of BP in order to prevent, reverse or delay the progression of complications and thus reduce the overall risk of an individual without adversely affecting the quality of life. Patients should be explained that the lifestyle modifications and drug treatment is generally lifelong and regular drug compliance is important
  39. 39. Initiation of therapy  Having assessed the patient and determined the overall risk profile, management of hypertension should proceed as follows:  In low risk patients, it is suggested to institute life style modifications and observe BP for a period of 2-3 months, before deciding whether to initiate drug therapy.  In medium risk patients, institute life style modifications and initiate drug therapy after 2-4 weeks, in case BP remains above 140/90.  In high and very high-risk groups, initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
  40. 40. Management Me d i c a l M a n a g e m e n t Lifestyle modifications Medications
  41. 41. Modification Recommendation Weight reduction Maintain normal body weight (body mass index, 18.4–24.9 kg/m2) Adopt DASH eating plan Consume diet rich in fruits, vegetables, low- fat dairy products, with reduced content of saturated and total fats Dietary sodium reduction Reduce dietary sodium intake to no more than 100 mmol/day (2.4g sodium or 6g sodium chloride) Physical activity Engage in regular aerobic physical activity (e.g., brisk walking) at least 30 min/day, most days of the week Moderation of alcohol consumption Most men: limit consumption to no more than two drinks/day‡ Most women and those who weigh less than normal: no more than one drink/day
  42. 42. Adopt DASH (Dietary Approaches to Stop Hypertension  Eating more fruits, vegetables, and low-fat dairy foods  Cutting back on foods that are high in saturated fat, cholesterol, and trans fats  Eating more whole grain products, fish, poultry, and nuts  Eating less red meat (especially processed meats) and sweets  Eating foods that are rich in magnesium, potassium, and calcium
  43. 43. DASH diet Food group No. of servings per day Grains and grain products 7 or 8 vegetables 4 or 5 fruits 4or5 Low fat or fat free dairy products 2or 3 Meat, fish, poultry 2 or fewer Nuts, seeds,and dry beans 4 or 5 weekly
  44. 44.  Different programs aimed to reduce psychological stress such a biofeedback, relaxation or meditation are advertised to reduce hypertension
  45. 45. Principles of drug treatment  Over the past decade, the goals of treatment have gradually shifted from optimal lowering of blood pressure, to patient’s overall well being, control of associated risk factors and protection from future target organ damage  Achieve gradual reduction of blood pressure. Use low doses of antihypertensive drugs to initiate therapy.  Five classes of drugs can be recommended as first line treatment for stage 1-2 hypertension1,2 These include :1) ACE inhibitors, 2) angiotensin II receptor blockers, 3) calcium channel blockers, 4) diuretics and 5) newer β-blockers.  The Blood Pressure Lowering Treatment Trialists’ Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk.
  46. 46. • Choice of an antihypertensive agent is influenced by age, concomitant risk factors, presence of target organ damage, other co-existing diseases, • socioeconomic considerations, availability of the drug and past experience of the physician. • Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects. In 60-70 % of patients, goal blood pressure will be achieved with two or more agents only. • Use of fixed dose formulations should be considered to improve compliance. • Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP. • Use of long acting drugs that provide 24-hour efficacy with once daily administration ensures smooth and sustained control of blood pressure; which in turn is expected to provide greater protection against the risk of major cardiovascular events and target organ damage. Once daily administration also improves patient compliance. • Although antihypertensive therapy is generally lifelong, an effort to decrease the dosage and number of antihypertensive drugs should be considered after effective control of hypertension (step-down therapy). • Due to a greater seasonal variation of temperatures in India, marginal alterations in dosages of drugs may be needed from time to time.
  47. 47. Medications  Several classes of medications, collectively referred to as antihypertensive drugs, are currently available for treating hypertension.. .One or more of these blood pressure medicines are often used to treat high blood pressure:  Diuretics are also called water pills. They help your kidneys remove some salt (sodium) from your body. As a result, your blood vessels don't have to hold as much fluid and your blood pressure goes down.
  48. 48.  Beta-blockers make the heart beat at a slower rate and with less force.  Angiotensin-converting enzyme inhibitors (also called ACE inhibitors) relax your blood vessels, which lowers your blood pressure.  . Angiotensin II receptor blockers (also called ARBs) work in about the same way as angiotensin-converting enzyme inhibitors
  49. 49. .  Calcium channel blockers relax blood vessels by stopping calcium from entering cells. Blood pressure medicines that are not used as often include:  Alpha-blockers help relax your blood vessels, which lowers your blood pressure.  Centrally acting drugs signal your brain and nervous system to relax your blood vessels.  Vasodilators signal the muscles in the walls of blood vessels to relax.
  50. 50.  Renin inhibitors, a newer type of medicine for treating high blood pressure, act by relaxing your blood vessels  Renin inhibitors work, as the name would suggest, by inhibiting the activity of renin, the enzyme largely responsible for angiotensin II levels. In clinical trials, renin inhibitors have proven effective in not only lowering blood pressure, but also keeping blood pressure levels steadier throughout the day.One renin inhibitor, aliskiren (Tekturna), was approved by the FDA in 2007. Other drugs in this class are in development
  51. 51.  Two new techniques to treat resistant hypertension that are undergoing clinical trials involve baroreceptor activation therapy and renal artery denervation in order to lower blood pressure:  Baroreceptor activation therapy is performed using a Rheos baroreflex hypertension therapy system which is surgically implanted in the subclavicular region. The electrodes connected to this device are attached to the carotid body on each side of the neck. Activation of baroreceptors leads to significant lowering of blood pressure.
  52. 52. The renal denervation system  uses a catheter to perform radiofrequency ablation when applied to the lumen of renal arteries through a femoral access. In a study, 153 patients with resistant hypertension (baseline BP of 176/98 + 17/15 mmHg) underwent catheter-based renal sympathetic denervation. Patients experienced a sustained BP reduction averaging 32/14 mmHg at 24 months; 92% had an office blood pressure reduction of >10mmHg and 97% of patients were free of procedure-related Complication
  53. 53. Conditions for which clinical trials demonstrate benefit of specific classes of antihypertensive drugs.  Heart Failure . In asymptomatic individuals with demonstrable ventricular dysfunction, ACEIs and BBs are recommended. For those with symptomatic ventricular dysfunction or end-stage heart disease, ACEIs, BBs, ARBs and aldosterone blockers are recommended along with loop diuretics.  Diabetic Hypertension  Combinations of two or more drugs are usually needed to achieve the target goal of <130/80 mmHg. Thiazide diuretics, BBs, ACEIs, ARBs, and CCBs are beneficial in reducing CVD and stroke incidence in patients with diabetes. ACEI- or ARB-based treatments favorably affect the progression of diabetic nephropathy and reduce albuminuria, and ARBs have been shown to reduce progression to macroalbuminuria.
  54. 54.  Chronic Kidney Disease: Hypertension appears in the majority of these patients, and they should receive aggressive BP management, often with three or more drugs to reach target BP values of <130/80 mmHg. ACEIs and ARBs have demonstrated favorable effects on the progression of diabetic and nondiabetic renal disease.  Cerebrovascular Disease  The risks and benefits of acute lowering of BP during an acute stroke are still unclear; control of BP at intermediate levels (approximately 160/100 mmHg) is appropriate until the condition has stabilized or improved. Recurrent stroke rates are lowered by the combination of an ACEI and thiazide-type diuretic.
  55. 55. Obesity and the metabolic syndrome  Intensive lifestyle modification should be pursued in all individuals with the metabolic syndrome, and appropriate drug therapy should be instituted for each of its components as indicated  Left ventricular hypertrophy Left ventricular hypertrophy (LVH) is an independent risk factor that increases the risk of subsequent CVD. Regression of LVH occurs with aggressive BP management, including weight loss, sodium restriction, and treatment with all classes of antihypertensive agents except the direct vasodilators hydralazine, and minoxidil.
  56. 56.  Peripheral arterial disease  Peripheral arterial disease (PAD) is equivalent in risk to IHD. Any class of antihypertensive drugs can be used in most PAD patients. Other risk factors should be managed aggressively, and aspirin should be used.  Hypertension in older persons  Hypertension occurs in more than two-thirds of individuals after age 65.This is also the population with the lowest rates of BP control.Treatment recommendations for older people with hypertension, including those who have isolated systolic hypertension, should follow the same principles outlined for the general care of hypertension
  57. 57. Hypertension in pregnancy  Women with hypertension who become pregnant should be followed carefully because of increased risks to mother and fetus. Methyldopa, BBs, and vasodilators are preferred medications for the safety of the fetus.ACEI and ARBs should not be used during pregnancy because of the potential for fetal defects and should be avoided In some patients, preeclampsia may develop into a hypertensive urgency or emergency and may require hospitalization, intensive monitoring, early fetal delivery, and parenteral antihypertensive and anticonvulsant therapy
  58. 58. Agent Onset Duration Advantages Disadvantages Nitroprusside Immediate 1-2 minutes Potent, titratable Cyanide, isocyanide Nitroglycerine 2-5 minutes 3-5 minutes Coronary perfusion Tolerance, variable efficacy Fenoldopam <5 minutes 5-10 minutes Renal perfusion Increased intraocular pressure Hydralazine 10-20 minutes 3-8 hours Eclampsia Tachycardia, headache Nicardipine 5-15 minutes 1-4 hours CNS protection Avoid in CHF and cardiac ischemia Enalaprilat 15-30 minutes 6 hours CHF, acute LV failure Avoid in MI Intravenous Agents for Hypertensive Emergencies
  59. 59. Complications of hypertension  Hypertension is the most important preventable risk factor for premature death.  Ischemic heart disease  Strokes  Peripheral vascular disease,  Other cardiovascular diseases  , Including heart failure, aortic aneurysms, diffuse atherosclerosis, and pulmonaryembolism
  60. 60.  Hypertension is also a risk factor for cognitive impairment and dementia, and chronic kidney disease. Other complications include hypertensive retinopathy and hypertensive nephropathy.  Bleeding from the aorta  Target organ disease,POVD, nephrosclerosis  Hypertensive encephalopathy
  61. 61. Nursing management  Assessment  History  Past and present medical history  Family history  Risk factors  symptoms  Physical examination  Checking vital signs
  62. 62. Nursing problems  Decreased Cardiac Output related to increased peripheral resistance and arterial stiffneff  Acute Pain secondary to hypertension  Activity Intolerance  Imbalanced Nutrition : more than body requirements  Deficient Knowledge  Ineffective therapeutic regimen
  63. 63. Researches  Sesame and rice bran oil can treat high blood pressure and cholesterol, study show Significant blood pressure, cholesterol level reductions Yoga benefits high blood pressure through promoting relaxation of the mind and body. Practicing yoga helps decrease the negative impacts of stress, including tension, shallow breathing and elevated heart rate. It also improves physical strength and flexibility, plus may assist with weight loss

×