This document discusses the relationship between obesity and hypertension. It defines obesity using body mass index (BMI) and notes that over 1 billion adults worldwide are overweight. Obesity is linked to increased risk of hypertension, as excess weight causes elevations in cardiac output and systemic vascular resistance over time. Weight loss through diet and exercise can significantly lower blood pressure in hypertensive patients by an average of 6.3/3.4 mmHg. Resistance training may also help reduce blood pressure when performed at a moderate intensity. Stress management techniques like meditation and yoga have also shown limited efficacy in lowering blood pressure.

1. HYPERTENSION
Relation Between Hypertension and Obesity
Mohammad Ilyas, M.D.
Assistant Clinical Professor
University of Florida / Health Sciences Center
Jacksonville, Florida USA
6/24/2014
1

2. Outline
1. Definition, Regulation and Pathophysiology
2. Measurement of Blood Pressure, Staging of Hypertension and Ambulatory
Blood Pressure Monitoring
3. Evaluation of Primary Versus Secondary
4. Sequel of Hypertension and Hypertension Emergencies
5. Management of Hypertension (Non-Pharmacology versus Drug Therapy)
6. The Relation Between Hypertension: Obesity, Drugs, Stress and Sleep
Disorders.
7. Hypertension in Renal diseases and Pregnancies
8. Pediatric, Neonatal and Genetic Hypertension
6/24/2014
2

3. Obesity
 Definition: excessive weight that may impair health
 How do we measure If someone is obese?
 Body mass index (BMI) – the weight in kilograms divided by the
square of the height in meters (kg/m2)
 BMI Categories:
 Underweight BMI < 18.5
 Normal weight = 18.5-24.9
 Overweight = 25-29.9
 Obesity = BMI of 30 or greater
 Morbid Obesity = BMI > 40
6/24/2014
3

4. Just the Facts! As of 2008 WHO
 Globally, More than 1.4 billion adults are overweight
 More than half a billion obese (>500,000,000)
 2.8 million people each year die as a result of being overweight
or obese.
 40 million preschool children were overweight
 overweight and obesity kills more people than underweight
 Projects by 2015, 2.3 billion will be overweight and 700 million
obese
6/24/2014
4

5. 6/24/2014
5

6. Childhood Obesity
Rates of childhood obesity are alarming
Problem is worldwide
Estimated in 2010, 42 million children
under age 5 are considered overweight
Tripled in past 30 years
Age 6-11 6.5% to 19.6%
Age 12-19 5.0% to 18.1%
6/24/2014
6

7. Childhood Obesity
 Genetic Link
Multi-factorial condition related to sedentary lifestyle,
too much food intake and choice of
foods actually alter genetic make-up, creating higher risk
of obesity
 Behavioral
Children will more likely choose healthier foods
if they are offered to them at young ages and
in the home
 Environment
In homes where healthy food is not available, or the food
choices are not healthy, obesity can occur
6/24/2014
7

8. Childhood Obesity
Why does this matter?
Premature death
Developing heart disease at younger ages
Developing diabetes type 2 at younger ages
What can be done?
Childhood obesity is preventable
Role of the schools
Role of health care professionals
6/24/2014
8

9. Cause of Obesity
Simple equation…when you eat more than
you use, it is stored in your body as “fat”.
Causes
Global shift in how we eat
Western diet of processed food
Higher sugar, fat and calories in what we eat
Less nutrients
Reduced intake of vitamins and minerals
6/24/2014
9

10. 6/24/2014
10

11. What does obesity do to our bodies?
With more people gaining too much weight..there
are health issues to consider
Cardiovascular disease
Diabetes type 2
Musculoskeletal disorders
Cancers-endometrial, cervical and colon
Infertility
Gallstones
Premature death and disability
6/24/2014
11

12. Heart Disease and Diabetes
Heart Disease
The world’s number #1 cause of death
Kills 17 million each year around the world
Heart attack
Stroke
Diabetes type 2
Becoming global epidemic
WHO projects diabetes will increase by 50% across the
world
6/24/2014
12

13. Hypertension
 Weight gain raises blood pressure
 Obesity further enhances total cardiovascular risk and all-
cause mortality
 Excess body weight accounted for approximately 26 percent
of cases of hypertension in men and 28 percent in women
 Approximately 23 percent of cases of coronary heart disease
in men and 15 percent in women
6/24/2014
13

14. BMI (>/= 25kg/m2)
Essential hypertension
78%-in male
65%-in female
(Vasant RS, Larson MG et al, 2001)
Dolls, Bovet P et al, 2002
6/24/2014
14

15. Body mass index and the risk of disease
6/24/2014
15

16. Adult weight change and the risk of disease
6/24/2014
16

17. PATHOGENESIS OF HYPERTENSION
 Initially, an elevation in cardiac output and a relatively normal
systemic vascular resistance (SVR).
 Later, obese subjects is an elevation in SVR in hypertensive.
 Increased activation of the renin-angiotensin aldosterone system.
 These hemodynamic alterations plus abnormalities in lipid and
glucose metabolism appear to be related to fat distribution as
well as to total body weight.
 In particular, the risk is greatest in those patients with abdominal
obesity, which is a major component of the metabolic syndrome.
6/24/2014
17

18. 6/24/2014
18

19. 6/24/2014
19

20. Hyperinsulinemia and Hypertension
 The mechanism by which obesity raises the BP is not well
understood.
 A variety of mechanisms have been proposed to explain how
hyperinsulinemia might increase BP
 Increased sympathetic activity
 Volume expansion due to increased renal sodium reabsorption
 Endothelial dysfunction
 Up regulation of angiotensin II receptors, and
 Decreased cardiac natriuretic peptide .
 Genetic susceptibility
Despite these observations, the role of insulin resistance or
hyperinsulinemia as a cause of hypertension remains unproven
6/24/2014
20

21. Sleep apnea syndrome
 The sleep apnea syndrome is an additional contributing
factor to the development of hypertension in obese
patients.
Activation of the sympathetic nervous system,
Enhanced aldosterone levels, and
Increased levels of endothelin by repeated episodes of hypoxia
are thought to be responsible in part for the elevation in
blood pressure in this disorder
6/24/2014
21

22. Leptin-melanocortin pathway
 The correlation between the serum concentration of leptin, a
protein that signals the brain about the quantity of stored fat,
and body fat content
 With increasing adiposity, leptin acts as a negative feedback
"adipostatic" signal to brain centers controlling energy intake
 The melanocortin receptor, which is expressed on downstream
targets of leptin and insulin responsive-neurons, is involved in
the regulation of energy balance and may also modulate blood
pressure
6/24/2014
22

23. Leptin pathway in hypertension development in obesity
6/24/2014
23

24. Weight reduction
6/24/2014
24

25. EFFECTS OF WEIGHT REDUCTION
 Weight loss may lead to a significant fall in systemic BP.
 A mean fall in blood pressure of 6.3/3.4 mmHg with weight loss diets.
 Weight reducing drugs, particularly orlistat, can also reduce blood
pressure,
 Weight loss surgery (eg, Roux-en-Y gastric bypass), in addition to lifestyle
interventions, also reduces blood pressure,
 The fall in blood pressure with weight loss is accompanied by a decrease
in arterial stiffness
 The decline in BP induced by weight loss can also occur in the absence of
dietary sodium restriction; however, modest sodium restriction (a
decline in intake of 20 to 40 meq/day) may produce an additive
antihypertensive effect
6/24/2014
25

26. EFFECTS OF WEIGHT REDUCTION
 Calorie expenditure > Calorie intake by 10%
 Net 3500 kcal energy burning gives 0.45 kg body fat loss.
 A meta analysis by staessen et al. showed that mean SBP & DBP
reductions were 1.6/1.1 mmHg per kg of body weight by aerobic
program.
 18 month weight loss program associated with 77% reduction in
incidence of hypertension.
(He J, Whelton PK et al.2000)
 The exact mechanism by which weight reduction lowers blood
pressure is not known.
6/24/2014
26

27. 6/24/2014
27

28. Resistance Training
 Strength exercise can even be used for lowering blood
pressure.
 The actual blood pressure response depends on:
• isometric component
• exercise intensity
• Muscle mass activated
• number of repetitions
• duration of contraction
• involvement of valsalva maneuver
Bjarnason – Wehrens B, Mayer – Berger W et al, 2004
6/24/2014
28

29.  However, a need exists for additional well designed studies on this
topic before a recommendation can be made regarding the efficacy
of resistance exercise as a non pharmacologic therapy for reducing
the resting blood pressure in hypertensive individuals.
Kelley G et al, 1997
6/24/2014
29

30. Isometric Exercise
 Isometric exercise such as weight lifting can have a pressor
effect and therefore should be avoided. Thus it is strictly
contraindicated.
(Krousel Wood MA, Muntner P et al, 2004)
6/24/2014
30

31. Long-term effects of weight reduction
 The persistence of weight loss provides substantial benefits
 Sustained weight loss of 6.8 kg or more was associated with a 22 -
26 % reduction in relative risk of developing hypertension
 Weight loss of 10 to 20 percent was associated with a reduction in
total and resting energy expenditure
 Increase in physical activity should always be added to diet
 Markedly obese patients may require surgical therapy to produce
and maintain an adequate degree of weight loss.
6/24/2014
31

32. SUMMARY AND RECOMMENDATIONS
 Obesity is an important risk factor for hypertension and all-cause
mortality.
 Weight loss can lead to a significant fall in blood pressure.
 Antihypertensive agents will often be necessary if adequate
weight loss cannot be achieved or sustained.
 Angiotensin converting enzyme inhibitors, angiotensin receptor
blockers, or dihydropyridine calcium channel blockers may be the
antihypertensive agents of choice.
6/24/2014
32

33. Hypertension: Personality Traits
Upset by criticism
Upset by imperfection
Pent up anger, bitterness
Low self-confidence
6/24/2014
33

34. Stress and Anxiety Control
 Meditation was in one study to reduce SBP and DBP by 10.7 mm Hg
and 6.4 mm Hg over a period of 3 months
Schneider RH Alexander CN et al, 1995
 Progressive muscle relaxation lower SBP by 4.7 mm Hg and DBP by
3.3mm Hg.
 Yoga is also widely believed to reduce blood pressure
Damodaran A, Patil N, Suryavanshi et al, 2002
 However, these interventions are with limited and uncertain efficacy.
Therefore more trials are needed to confirm its effect.
6/24/2014
34

35. 6/24/2014
35

36. Conclusion
 Hypertension is a silent killer.
 Cardiopulmonary Physiotherapy is an integral part of
health service.
 Evidence supports that exercise is the cornerstone for
hypertension control, then why it is not being utilized.
 This is the time, physiotherapist must emerge and show
their potential to beat paramount disorder like
hypertension where even pharmacological management
fails.
6/24/2014
36