Obesity is one of the most visible, yet the most neglected, risk factors contributing to the overall burden of diseases worldwide. It is estimated that at least one billion adults and ten per cent of children are now overweight or obese. Obesity leads to various diseases such as cardio-vascular disease, hypertension, type 2 diabetes, osteoarthritis, or even some type of cancer.
The main cause of the obesity epidemic is clear: overeating, especially that food items, which are rich in fats, extracted sugar, or refined starches. This is linked to a progressive decline in physical activity, which results in an imbalance of intake and expenditure of calories, resulting into excess weight and eventually obesity. When it combines with hypertension, it makes deadly combination. On the top of it if you neglect yourself and do not take medical help, you bring disaster in your family.
I am a gynaecologist and not cardiologist but in last two years, a number of people, dear to me lost their life just because they neglected their health. I decided to plead to public to lead a public movement against obesity and hypertension.
Patients taking treatment for obesity should take treatment seriously. Any lapse on part of the treatment can lead to disastrous results.
There are few cases which I have come across. One is of a 47-year-old hypertensive and obese woman, who left treatment during Navaratri days ? developed severe headache ? massive brain haemorrhage and died after remaining on ventilator for ten days.
An obese and hypertensive boy of 26 years, only son of parents, never bothered about his health, believed in only fun, developed severe headache early morning, went into deep coma, diagnosed to have massive brain haemorrhage and died after being on ventilator for 12 days.
The common denominator in all cases was ? not caring about their obvious high risk factors, i.e obesity/hypertension and probably undiagnosed diabetes which took their life untimely.
Hypertension, commonly referred to as ?high blood pressure?, is a medical condition in which the blood pressure is chronically elevated. Hypertension has been associated with a higher risk of heart attack or stroke.
Hypertension can be classified as either essential (primary) or secondary. Essential hypertension indicates that no specific medical cause can be found to explain a patient'scondition. Secondary hypertension indicate that the high blood pressure is a result of (i.e secondary to) another condition, such as kidney disease or certain tumours (especially of the adrenal gland).
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure has defined blood pressure 120/80 mmHg to 139/89 mmHg as ?pre-hypertension and should not be neglected?. The American Heart Association treats hypertension as a silent killer. It'san apt term. As a major cause of strokes, heart attacks, and kidney diseases, high blood pressure can be lethal; the higher the pressure, the higher the risk. And since most people feel perfectly well until it has produced permanent damage, the disease often escapes notice. The only way to know if you have hypertension is to have your blood pressure checked regularly and avoid high risk factors.
Hypertension should also be known as the silent epidemic. Prevalence of sustained hypertension is on the rise in urban areas even in younger age groups. A community-based sample in Kerala established that over half of all middle-aged individuals were hypertensive, but less than a third were under treatment. Adequate control of hypertension was achieved in less than a third of the treated individuals. Though a growing number of Indians have high blood pressure, but a significant number don'tknow it. And as our population grows older, heavier and more sedentary, this silent epidemic is sure to grow and harm society.
Distinguishing between primary and secondary hypertension
Once the diagnosis of hypertension has been made it is important to attempt to exclude or identify reversible (secondary) causes. Over 90 per cent of adult hypertension has no clear cause and is therefore called essential/primary hypertension. Often, it is part of the metabolic ?syndrome X? in patients with insulin resistance; it occurs in combination with diabetes mellitus (Type 2), combined hyperlipidemia and central obesity.
Obesity and hypertension: Two epidemics or one?
In line with the global epidemic, obesity is indeed weighing heavily on India as well. The link between obesity and hypertension is well known, but the exact nature of the association between the two disorders remains unclear.
Today almost 29 per cent of the population is hypertensive (having a blood pressure (BP) greater than 140/90 mmHg or using hypertensive medications). The relationship between obesity and BP appears to be linear and exists throughout the non-obese range. Approximately 70 and 75 per cent of the cases of hypertension in men and women, are directly attributed to an overweight condition and obesity.
Organ damage can result from obesity hypertension combination. Elevated blood pressure due to obesity can cause long-term damage to the body'svital organs and functions. This damage can occur to the heart and vascular system.
There is increasing evidence that obesity is associated with an increase in central arterial stiffness causing problem of stroke and heart attack and weight loss reduces arterial stiffness.
Treatment options for obesity hypertension. Non-pharmacological approach.
Weight loss: Weight loss is considered the most effective non-pharmacological therapy for lowering BP in obese hypertensive cases. There is a dose-response relation between the degree of weight loss and the reduction in BP that is independent of sodium intake. Even modest weight loss of 5-10 per cent of body weight is associated with clinically significant reductions in BP and its complications.
Regular physical activity: The incidence of hypertension is highest in obese sedentary and lowest in lean physically active individuals. Physically active individuals have a lower risk of hypertension compared with their sedentary counterparts. Importantly, the risk of hypertension associated with weight gain also appears to be lower in physically active individuals. As such, regular physical activity is recommended for individuals with elevated BP. For Indians normal BMI is 18.5 ? 23 kg/m2 . Over 30 it is obesity and above 40 it is morbid obesity.
Sodium restriction: Sodium restriction reduces BP, albeit modestly, in obese individuals. However, additional research has reported that moderate sodium restriction resulted in dramatic reduction in BP in obese postmenopausal women.
Combination anti-hypertensive therapy
Many patients will not have their blood pressure controlled by one drug alone. As most anti-hypertensive agents have fairly flat dose-response curves, using large doses of a single agent will produce significant increase in side-effects without much further fall in blood pressure. Effective combination therapy will use drug with different primary modes of action.
Diuretic are synergistic with most other agents, except the calcium cannel blockers.
Anti-hypertensive for the obese
Unfortunately, there is limited data on the safety and efficacy of common anti-hypertensives for the obese. The results of most of the anti-hypertensive trials are more applicable to non-obese patients than to patients with BMI of 35kg/m2 (grade II obesity) or above. The lack of specific recommendations for the obese hypertensive patient is far from trivial. Pharmacological treatment of obesity may be a logical approach for lowering BP in obese individuals. However, only two drugs, sibutramine and orlistat, have been approved by US-FDA for long-term use in weight loss and weight management. But patients achieving five per cent or more weight loss have a decline in blood pressure that correlates with the decline in weight. Moderate weight loss improves metabolic and cardiovascular risk factors and prevents the progression to type 2 diabetes.
The challenge for anti-obesity management is clear: The anti-obesity treatment needs to be aggressive to help reduce weight while managing hypertension. Obesity awareness and management has entered a very interesting phase in western world, with the focus on not only pharmacotherapy but in overall management strategies to ensure long-term success of treatment of obesity. Sibutramine is the only US-FDA-approved drug for long-term management of obesity. It is sold as over the counter drug and is backed by more than a decade of clinical experience in managing obesity. There are more than 100 clinical studies in humans with sibutramine. But these drugs only help. One should restrict diet and do well-planned exercise regimen. Simply taking drugs do not help individuals.
In summary, obesity and hypertension have synergistic effects leaving the obese hypertensive patients at high risk for a lot of cardiovascular and metabolic complications including left ventricular hypertrophy, insulin resistance, impaired glucose tolerance, type 2 diabetes and dyslipidaemia, making them prone for untimely death with stroke and heart attack.
To avoid all this, public movement should be started in India about regular medical check-ups.
(The writer is Secretary General, Delhi Gynaecologist Forum.)