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Canadian Journal of Cardiology 28 (2012) 326 –333

The Obesity Epidemic and Its Impact on Hypertension
Thang Nguyen, MD, FRCPC,a and David C.W. Lau, MD, PhD, FRCPCb
Division of Cardiology, Cardiac Prevention and Rehabilitation, St Michael’s Hospital, Toronto, Ontario, Canada
Departments of Medicine, Biochemistry and Molecular Biology, and Cardiac Sciences, Julia McFarlane Diabetes Research Centre, University
of Calgary, Calgary, Alberta, Canada

Global obesity rates have increased steadily in both developed and Le taux d’obésité globale a augmenté de manière régulière dans les
emerging countries over the past several decades with little signs of pays développés et les pays émergents au cours des dernières décen-
slowing down. Over 1.5 billion people worldwide are overweight or nies, tout en montrant de légers signes de ralentissement. Plus de 1,5
obese and over 40 million children under the age of 5 are overweight. milliard de personnes dans le monde sont préobèses ou obèses, et
Obesity is associated with increased morbidity, disability, and prema- plus de 40 millions d’enfants de moins de 5 ans sont préobèses.
ture mortality from cardiovascular disease, diabetes, cancers, and L’obésité est associée à une augmentation de la morbidité, de
musculoskeletal disorders. The personal and societal health and eco- l’incapacité et de la mortalité prématurée en raison des maladies
nomic burden of this preventable disease pose a serious threat to our cardiovasculaires, du diabète, des cancers et des troubles muscu-
societies. Obesity is a major risk factor for hypertension and cardio- losquelettiques engendrés. La santé personnelle et sociale ainsi que le
vascular disease. Weight loss, through health behaviour modification fardeau économique de cette maladie évitable posent un sérieux
and dietary sodium restriction, is the cornerstone in the treatment of problème à nos sociétés. L’obésité est un facteur de risque majeur de
obesity-related hypertension. Pharmacotherapy and bariatric surgery l’hypertension et des maladies cardiovasculaires. La perte de poids,
for obesity are adjunctive measures when health behaviour interven- par la modification des comportements de santé et par la restriction
tions fail to achieve the body weight and health targets. Successful en sodium alimentaire, est la pierre angulaire dans le traitement de
management of overweight and obese persons requires a comprehen- l’hypertension liée à l’obésité. La pharmacothérapie et la chirurgie
sive, multifaceted framework that integrates population health, public bariatrique sont des moyens auxiliaires lorsque les interventions en
health, and medical health models to dismantle the proximal and matière de comportement de santé ne mènent pas aux objectifs de

Obesity has reached epidemic proportions globally and has ing on the severity of obesity the life expectancy of overweight
become a major public health concern.1 In 2008 an estimated and obese adults is shortened by 4 to 10 years. Globally 3
1.5 billion adults worldwide were overweight and 500 million million deaths annually have been attributed to obesity.2
were obese. More than 40 million children under the age of 5 The excess mortality among overweight and obese (defined
are overweight.2,3 Obesity rates have more than doubled since as BMI ⬎ 30) people is due mainly to cardiovascular causes.
1980, with 1 in 10 of the world’s adult population now According to the World Health Organization, more than a
obese.2,3 Adiposity, or excess body fat, is associated with in- third of the world’s deaths can be attributed to a small number
creased morbidity, disability, and premature mortality from of risk factors. Among the 5 leading risk factors are high blood
cardiovascular disease (CVD), diabetes, cancers, and musculo- pressure (BP), tobacco use, high blood sugar, physical inactiv-
skeletal disorders. Using body mass index (BMI) (calculated as ity, overweight, and obesity.2 High BP, obesity, and physical
weight [kg]/height [m2]) as an anthropometric measure of ad- inactivity each accounted for 395,000, 216,000, and 191,000
iposity, each 5 units above the overweight category (BMI ⬎ preventable deaths in 2005 in the US.5 Except for tobacco use,
25) is associated with approximately 30% higher overall mor- 4 of the 5 risk factors are interrelated— both hypertension
tality and 40% higher for cardiovascular mortality.4 Depend- and high blood sugar could be attributable to unhealthy
behaviours such as food overconsumption and physical in-
Received for publication December 8, 2011. Accepted January 2, 2012. activity, which in turn may lead to the development of over-
Corresponding author: Dr David C.W. Lau, Departments of Medicine, weight and obesity. Indeed, obesity has eclipsed cigarette
Biochemistry and Molecular Biology, and Cardiac Sciences, Julia McFarlane smoking as the leading preventable cause of death and short-
Diabetes Research Centre, University of Calgary, 2998-3330 Hospital Drive ened life expectancy in the US.6
NW, Calgary, Alberta T2N 4N1, Canada. Tel.: ⫹1-403-220-2261; fax: ⫹1-
Hypertension is a common feature present in a large pro-
E-mail: dcwlau@ucalgary.ca portion of overweight and obese people. It is correlated with
See page 331 for disclosure information. the degree of obesity and greatly exaggerates the risk of stroke,

0828-282X/$ – see front matter © 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
Nguyen and Lau 327
Obesity and Hypertension

distal drivers of the obesogenic environment in which we live. Preven- poids corporel et de santé. La prise en charge réussie des per-
tion of obesity is no longer a lofty but rather necessary goal that sonnes préobèses et obèses requiert un cadre multifacette, détaillé
urgently calls for action from governments at all levels, in conjunction et complet, qui intègre les modèles de santé de la population, de
with all public and private sector stakeholders, in order to combat a santé publique et de santé médicale pour éliminer les facteurs
serious and growing public health concern. proximaux et distaux de l’environnement obésogène dans lequel
nous vivons. La prévention de l’obésité n’est plus un but noble, mais
plutôt un but nécessaire qui exige de manière urgente l’intervention
de tous les ordres de gouvernement, conjointement avec toutes les
parties prenantes des secteurs public et privé, pour combattre ce
sérieux et croissant problème de santé publique.

coronary artery, and peripheral artery diseases. The burden of obesity is significantly higher among aboriginal peoples in both
hypertension attributable to obesity is very high, and has been adults and children.14
estimated to be approximately 80% for men and approximately The increasing prevalence of overweight and obesity in chil-
60% for women.7 The odds ratio for hypertension is 1.7 for dren and youth is particularly disturbing as childhood obesity
overweight compared with normal weight individuals, 2.6 for is predictive of adult obesity.1,17 What is even more alarming
class 1 obesity (BMI 30-34.9), 3.7 for class 2 obesity (BMI is the observation that clustering of CVD risk factors is
35-39.9), and 4.8 for class 3 obesity (BMI ⬎ 40).8 already present in overweight children, leading to an in-
This review focuses on the relationship of obesity and hy- creased future risk of CVD in adults.18,19 When these fig-
pertension in adults and children, the mechanisms linking obe- ures are applied to a computer-simulation model of coro-
sity to hypertension, why weight loss is a cornerstone treatment nary artery disease (CAD) to predict excess incidence and
for obesity-related hypertension, and approaches to tackle the prevalence of CAD from 2020 to 2035, the prevalence of
global epidemic of obesity. CAD will increase by a range of 5% to 16% by 2035, and
more than 100,000 excess cases of CAD will be directly
The Global Epidemic and Burden of Obesity attributable to childhood obesity.13 Furthermore, a recent
Globally the prevalence of obesity has been steadily increas- study in a large cohort of 276,835 Danish school children
ing over the past several decades. Data from over 9 million found that the CVD risks during adulthood increased linearly
adults in 199 countries have indicated that the BMI increased with increasing BMI at each age from 7 to 13 years.19 Another
by 0.4-0.5 per decade worldwide between 1980 and 2008.9 prospective study in 37,674 apparently healthy young men,
The dramatic rise in obesity rates globally is fueled by the in- which tracked BMI from adolescence to adulthood with a
creased availability of energy-dense diets, increasingly seden- mean follow-up of 17 years, indicated that an elevated BMI at
tary physical activity behaviours and, importantly, mass urban- age 17 years— one that is in the high normal range—was asso-
ization in emerging nations. The proportion of the world’s ciated with substantially higher risk of CAD in adulthood at
population living in urban areas eclipsed the 50% mark in age 30 years.20 The hazard ratio for the association of adoles-
2008, with the urban population predicted to increase to 4.9 cent BMI with CAD, after multivariate analysis adjusted for
billion by 2030, while the rural population is expected to con- age, family history, BP, lifestyle factors, fasting glucose, and
tract by 28 million.10 Obesity is a consequence of the obeso- triglyceride levels, was 6.85.20 Available evidence has led many
genic environments that have evolved in both high and low experts to predict that the current generation of overweight and
income countries. Urbanization is increasingly viewed as a po- obese children may have a shorter life span than their par-
tential health hazard for vulnerable populations, namely the ents.18,21 Fortunately a recent study of 6,328 subjects with a
urban poor from both high and low income countries. mean follow-up of 23 years, reported that if childhood obesity
The US leads the developed world with the highest obesity is reduced or treated, the increased CVD risk in adulthood
rates, with a prevalence of 34% in adults and 17% among could be attenuated. The CVD risks among people who were
children 2-19 years of age.11 Projections based on the current overweight or obese as children but are no longer obese as
obesity trends predict that there will be 65 million more obese adults were similar to the CVD risks in those people who were
adults in the US by 2030.12 In Canada, the 2007-2009 cohort never obese.22 This study suggests that childhood obesity, if
from the Canadian Health Measures Survey had a 2.0 increase successfully treated, does not necessarily increase the CVD risk
in mean BMI when compared with the 1981 data.13 Twenty- permanently during adulthood.
five percent of Canadian adults and 8.6% of children and Obesity increases the risk of many chronic diseases, notably
youth aged 6-17 were obese.14 The mean BMI of adult Cana- type 2 diabetes, hypertension, heart disease, stroke, musculo-
dians is greater than 25 regardless of age or gender. Based on the skeletal diseases, and several forms of cancers. The acute and
measured data, the prevalence of overweight and obesity in chronic diseases associated with excess adiposity not only neg-
2008 was an alarming 62%.14 Nineteen percent of men and atively affect the health-related quality of life of an individual,
21% of women between the ages of 20 to 39 were classified as but also the substantially higher costs from health care and lost
obese, while for ages 60 to 69 years, the prevalence increased to productivity to the individual and the society. A systematic
34% and 33% respectively.15 In adolescents aged 15 to 19 review demonstrated that obesity accounts for 0.7%-2.8% of
years, 25% of girls and 31% of boys were already overweight or direct health care expenditure in many developed countries but
obese.16 If the obesity trend continues at the current rate, half could be as high as 7% in the US.23 Data from the US indicate
of the Canadian population over the age of 40 years will be that obese people incur more frequent physician visits, higher
classified as obese within 25 years.15 Sadly, the prevalence of in- and out-patient costs, and greater prescription drug use.12
328 Canadian Journal of Cardiology
Volume 28 2012

In Canada, the total direct health care costs attributable to have been proposed to explain the positive relationship. First,
obesity have escalated from CAD$1.8 billion (2.4% of the total leptin alters renal sodium by upregulating renal Na, K-ATPase
health expenditures) in 1997 to CAD$4.6 billion in 2006 activity.32 Second, leptin also activates the renin-angiotensin-
(4.1% of the total health care expenditures).24,25 In addition to aldosterone axis as well as the sympathetic nervous system,
medical costs, the indirect costs from obesity as a result of both of which could lead to the development of hyperten-
decreased years of working life, disability-free life, and work sion.32 Third, higher leptin levels may be related to insulin
absenteeism vs presenteeism are difficult to quantify but could resistance which is also associated with hypertension.33,34 Fi-
be quite significant. Taken together these data indicate that nally, leptin could act in concert with other proinflammatory
obesity exacts a huge health and economic burden from both cytokines to induce vascular oxidative stress and arterial hyper-
individuals and the society. tension.34
Excess adipose tissue in overweight and obese people, espe-
cially from the visceral depot, becomes dysfunctional, and is
Causal Link Between Obesity and Hypertension characterized by a preponderance of hypertrophied adipocytes
Hypertension is the most common cardiovascular risk fac- with infiltration by macrophages. These changes lead to exces-
tor predisposing to CAD, stroke, and structural end organ sive release of cytokines and proinflammatory mediators from
damage.2 The link between obesity and hypertension has been adipose tissue, often referred to as adipokines. In addition to
documented in many large population and epidemiological leptin, interleukin-6, tumour necrosis factor-␣, plasminogen
studies in adults and the burden of hypertension attributable to activator inhibitor-1, and C-reactive protein are among the
obesity is very high in both men and women.7,8 Population- proinflammatory akipokines that are upregulated in adipose
based studies consistently demonstrate an increased risk in the tissue and contribute to the systemic inflammatory state and
development of hypertension among overweight and obese the increased vascular oxidative stress observed in obesity.30
people. Compared with normal weight cohorts, obese individ- Adiponectin, a protein abundantly produced by adipose tissue,
uals have a 2- to 3-fold risk for developing high BP.26 The is an important stimulant of nitric oxide synthase activity and
mean systolic BP (SBP) and diastolic BP (DBP) values were confers protection against oxidative stress and insulin resis-
estimated to be 9 and 7 mm Hg higher in obese men and 11 tance. Circulating levels of adiponectin are decreased in obesity
and 6 mm Hg higher in obese women relative to a cohort with partly because its production is suppressed by the proinflam-
normal BMI.27 matory adipokines. Taken together, the unopposed upregula-
The observations that overweight and obese children with tion of proinflammatory adipokines and the suppression of
elevated BP may already have structural arterial abnormalities, adiponectin wreak havoc on glucose and lipid metabolism, re-
such as increased carotid intimal-medial thickness and left ven- sulting in vascular endothelial dysfunction, and the progression
tricular mass, suggests a causal relationship between obesity of atherosclerotic changes within the vessel wall.30,31 These
and hypertension.19,21 Obese adolescents have elevated 24- metabolic abnormalities not only exaggerate the risks for CVD
hour ambulatory BP readings compared with their nonobese but also insulin resistance and type 2 diabetes, and have led to
cohorts, with excess values as high as ⫹19.3 mm Hg systolic the development of the metabolic syndrome concept,30,35
and ⫹10.1 mm Hg diastolic in 1 study.28 Not surprisingly, the more broadly referred to as cardiometabolic risk.36
risk of developing hypertension increases with body weight. A A common feature of hypertension is the activation of the
Canadian cohort demonstrated a 7-fold likelihood of develop- renin-angiotensin-aldosterone axis. Animal studies suggest that
ing hypertension in obese children.29 It is not known whether adipose tissue is a source of angiotensinogen, angiotensin-con-
weight loss or treatment of hypertension will completely re- verting enzyme, and renin, where its contribution to the circu-
verse the structural arterial changes that have occurred in over- lating levels of these components of the renin-angiotensin-al-
weight and obese adolescents. Obesity-related hypertension is dosterone axis becomes an important consideration in the
increasingly recognized by some experts as a distinct phenotype presence of obesity.37 The finding of adipocyte hypertrophy,
that requires a more vigilant approach to diagnosis, treatment, low body weight and low BP in angiotensin knock-out mice
and prevention. lends support to a more direct role of adipose tissue in the
The hallmark of obesity is the presence of excessive body fat, pathogenesis of hypertension.37
which is the consequence of either overconsumption of food, It should be noted that hyperinsulinemia and insulin resis-
decreased physical activity, or both. Adipose tissue is composed tance in obesity can also induce hypertension via other mech-
of mature adipocytes, preadipocytes, endothelial cells, and anisms, including chronic stimulation of sympathetic and vas-
macrophages, and is no longer merely viewed as a passive re- cular tone along with antinatriuretic effects.30,37
pository for triacylglycerol. Mature adipocytes are active endo- There are other mechanisms whereby obesity could contrib-
crine and paracrine cells secreting an ever-increasing number of ute to the development of hypertension. For example, sleep
mediators that participate in diverse metabolic processes.30,31 apnea, a common complication of obesity, could alter the hy-
The best-known adipose tissue-derived hormone is leptin, pothalamic-pituitary-adrenal axis by inducing higher cortisol
which functions as a feedback regulator to suppress appetite levels, as well as activating the sympathetic nervous system.
centrally in the hypothalamus.31 Circulating leptin levels are
correlated to adiposity and are elevated in obese people.31 It
turns out that many overweight and obese people develop cen- Health Behaviour Management of Obesity-
tral leptin resistance and their appetites are not suppressed de- Related Hypertension in Adults
spite higher plasma leptin levels. Leptin has been linked to The cornerstone treatment of obesity-related hypertension
hypertension and this association was first reported in animal is weight loss through health behavioural changes and reduced
and more recently in human studies.32-34 Several mechanisms sodium intake in the diet. Weight loss diminishes both the
Nguyen and Lau 329
Obesity and Hypertension

Table 1. Expected BP response to obesity intervention fruits and vegetables, and low-fat dairy products, with reduced
SBP/DBP (mm Hg) saturated and total fat, the SBP and DBP were reduced by 11.4
Intervention Adults Adolescents mm Hg and 5.5 mm Hg respectively in people with hyperten-
sion when compared with the control diet.42 When the DASH
Health behaviour modifications ⫺6.6/⫺5.1 ⫺7/⫺2
Aerobic exercise only ⫺3.8/⫺2.6 No data diet was administered with dietary sodium restricted from 3.5
DASH - sodium restriction ⫺11.4/⫺5.5 No data g/d to 1.2 g/d, there was a further reduction in SBP 7.1 mm Hg
Orlistat ⫺2.5/⫺1.9 ⫹1.1 (NS)/⫺0.51 in people without hypertension and 11.5 mm Hg in people
Adjustable gastric banding ⫹2.1/⫺1.4 (NS) ⫺12.5/⫺6.0 with hypertension.43 Sodium restriction is particularly relevant
Roux-en-Y gastric bypass ⫺4.7/⫹10.4 (NS) Insufficient data
and effective in overweight and obese people, as they have a
BP, blood pressure; DASH, Dietary Approaches to Stop Hypertension; greater propensity for sodium retention as a direct consequence
DBP, diastolic BP; NS, statistically nonsignificant difference from control of the abnormal metabolic changes described earlier.
group; SBP, systolic BP. A recent US study suggested that reducing dietary salt by 3
g/d could reduce the annual number of new cases of CAD by
60,000 to 120,000, stroke by 32,000 to 66,000, and myocar-
augmented renin-angiotensin-aldosterone axis activity and the dial infarction by 54,000 to 99,000, in conjunction with an
activation of the sympathetic nervous system. Reduction in annual reduction in deaths from any cause by 44,000 to
body fat, especially from the visceral depot, improves insulin 92,000.44 The authors concluded that modest reductions in
resistance and also promotes natriuresis. The general principle dietary salt could substantially reduce cardiovascular events,
of weight loss is the achievement of a net negative energy bal- resulting in an estimated savings of USD$10 billion to
ance. This can be accomplished by health behaviour modifica- USD$24 billion in health care costs, and should therefore be
tion alone, or with adjunctive pharmacotherapy, and in some recommended as a public health target.
selected cases, bariatric surgery. Adoption of a healthier lifestyle
is essential for the long-term success in achieving lower BP
Pharmacotherapy for Obesity
values. This includes appropriate weight loss to achieve target
Pharmacotherapy for obesity is considered as an adjunct
health goals, maintenance of weight loss, and prevention of
when health behavioural changes fail to achieve the goal
weight regain, regular physical activity, reduced dietary sodium
targets in BP and/or other metabolic comorbidities.1 Cur-
intake, moderation of alcohol consumption, smoking cessa-
rently, orlistat is the only drug approved as a long-term
tion, and stress management. The necessary health behaviour
weight loss medication. Orlistat is a gastrointestinal lipase
modifications can best be delivered by an interdisciplinary
inhibitor that reduces dietary fat absorption and fat calorie
health care that includes dietary and exercise counselling, social
intake by approximately 30%.45 As expected, the common
support, and possibly cognitive behavioural therapy.
side effects include bloating, fecal incontinence, and ab-
The efficacy of health behaviour modification on BP in
dominal cramps. After 4 years, orlistat can maintain a neg-
overweight patients is partly dependent on the magnitude of
ative weight change of about 6 kg and a reduction of SBP
weight loss. A decrease of as little as 2 kg can reduce SBP by 4
and DBP of 4.9 and 2.6 mm Hg respectively. However, the
mm Hg and DBP by 3 mm Hg.38 A meta-analysis of 25 ran-
additional benefit of orlistat on top of health modification
domized trials concluded that a weight loss of 5.1 kg achieved alone was minimal, only achieving an additional 1.5 mm Hg
by energy restriction, increased physical activity, or both, can SBP and 0.7 mm Hg DBP reduction.46 Overall, a recent
lower SBP by 4.4 mm Hg and DBP by 3.6 mm Hg (see meta-analysis of 4 orlistat trials concluded a net BP benefit
Table 1). Each kg weight loss is associated with a reduction of of ⫺2.5 mm Hg SBP and ⫺1.9 mm Hg DBP.47
1 mm Hg in SBP of and 0.92 mm Hg in DBP.39 Weight loss Several antiobesity drugs are currently in phase 3 clinical
exceeding 5 kg is associated with more significant BP lowering, trials. One that is showing promise is liraglutide, a glucagon-
up to a 6.6 mm Hg reduction in SBP and 5.1 mm Hg reduc- like peptide-1 analogue currently approved as an antihypergly-
tion in DBP.40 This BP lowering effect becomes more dramatic cemic agent in most countries, which revealed greater weight
in patients with class II (BMI 35–39.9) or class III (BMI ⬎ 40) loss (⫺5.5 to ⫺7.2 kg) compared with orlistat (⫺4.1 kg).48
obesity. In this subset, reduction of 15 mm Hg SBP and 6 mm Liraglutide also reduced BP modestly (⫺5.6 to ⫺6.9 mm Hg
Hg DBP was possible if a 10 kg weight loss achieved through SBP and ⫺1.2 to ⫺2.9 mm Hg DBP). Data from a large phase
diet and physical activity intervention was maintained for 1 III trial involving a combination of phentermine and topira-
year.39 mate demonstrated a 10 kg weight loss, along with a BP reduc-
Aerobic exercise also lowers BP in both hypertensive and tion of 5.6 mm Hg SBP and 3.8 mm Hg DBP at 56 weeks.49
normotensive subjects. A meta-analysis of 54 randomized
controlled trials concluded that aerobic exercise was associ-
ated with a reduction in both SBP and DBP, 3.8 mm Hg Bariatric Surgery
and 2.6 mm Hg, respectively.41 The average intervention- At present bariatric surgery is considered for individuals
related weight loss was 0.4 kg, which was not statistically or with class III obesity (BMI ⬎ 40) or class II obesity (BMI ⬎
clinically significant. However, this points to the mecha- 35) with comorbid conditions such as hypertension and type 2
nism whereby exercise lowers BP independent of weight diabetes.1 Bariatric surgery procedures can be classified as re-
loss, potentially through improvements in insulin resistance strictive, malabsorptive, or combination of both restrictive and
and hyperinsulinemia. malabsorptive. Four types of bariatric procedures are now
Dietary patterns also appear to exert beneficial effects on BP available in Canada.
lowering. The best studied is the Dietary Approaches to Stop Firstly, adjustable gastric banding is a restrictive procedure
Hypertension (DASH) diet. Following an 8-week diet rich in that involves the placement of an adjustable silicone band
330 Canadian Journal of Cardiology
Volume 28 2012

around the upper portion of the stomach to reduce its overall Two randomized controlled trials involving orlistat have been
size. The absolute weight loss is about by 27 kg or 47% of studied in the pediatric population, with only 1 reporting BP
excess weight50 but its effect on hypertension has been disap- changes.62,63 In the 54-week trial orlistat was superior to health
pointing, with minimal improvement in subjects followed pro- behaviour modifications alone with respect to weight loss, re-
spectively for up to 10 years.51 ducing BMI by a modest 0.55. No difference in SBP was
Secondly, gastric bypass, or Roux-en-Y, is the gold standard noted, while DBP was reduced by a mere 0.5 mm Hg.
procedure, whereby the size of the stomach is reduced to create For the massively obese adolescent, bariatric surgery is
a smaller pouch that is connected to a small segment of the sometimes considered. Laparoscopic adjustable gastric band-
proximal jejunum. Mean absolute weight loss of gastric bypass ing and the Roux-en-Y procedure are the 2 procedures per-
surgery is 43 kg and the mean excess weight loss is 62%.50 formed to date and most of the published data consist of small
Using retrospective observational data, gastric bypass surgeries observational and not randomized studies, with follow-up in
appear to improve or resolve hypertension in the range of 30% the range of 1 to 5 years. Several studies reported improvement
to 70% after 1 to 5 years.50,52-55 The Swedish Obese Subjects in hypertension but lacked details. A prospective randomized
(SOS) study is the largest and longest prospective trial of bari- laparoscopic adjustable gastric banding trial in 50 adolescents
atric surgery to date and included a portion of gastric bypass with BMI ⬎ 35 reported a mean weight loss of 34.6 kg after 2
surgeries. At 10 years, there was a nonsignificant effect on BP in years. This was accompanied by a reduction in SBP of 12.5 mm
this subgroup despite a significant weight loss.51 Hg and DBP of 6.0 mm Hg when compared with baseline, but
Thirdly, vertical sleeve gastrectomy is a relatively new re- was statistically nonsignificant when compared with the con-
strictive procedure: the stomach is stapled vertically, thereby trol group.64 Limited data exists for Roux-en-Y gastric bypass
removing about 85% of the original stomach area. It can be a surgery, which is reserved for adolescents with severe obesity
stand-alone procedure, or as a first step for the gastric bypass (BMI ⱖ 50). However, significant improvements in hyperten-
surgery mentioned above. A Canadian registry of 34 patients sion are reported with substantial weight loss within 1 year of
showed a mean weight loss of 27.4 kg and a 53% resolution of observation.65,66
hypertension at a mean follow-up of 10 months.56 These find-
ings are consistent with other reports on laparoscopic sleeve
gastrectomy, which demonstrated a 40%-60% rate of hyper- Proposed Approaches to Tackle the Obesity
tension resolution in the short-term.57,58 The above 3 bariatric Epidemic and Its Impact on Hypertension
procedures are mainly performed laparoscopically; conse- The global pandemic of obesity can only be effectively re-
quently, peri- and postoperative complications are reduced versed by dismantling the principal determinants of the obeso-
drastically. genic environment. Obesity is a serious public health concern
Fourthly, the most technically challenging procedure is bil- and is a consequence of people responding normally to the
iopancreatic diversion with duodenal switch. Subtotal gastrec- obesogenic environment where more processed, energy-dense,
tomy is performed to create a sleeve-shaped stomach, and the affordable, and effectively marketed food are in abundant sup-
small bowel is divided into 2 limbs—the enteric limb carrying ply, in association with increasingly sedentary physical activity
food, and the biliopancreatic limb carrying bile and pancreatic behaviours promoted by the built environment and urbaniza-
juice, and an ultra-short common channel after anastomosis of tion. Undeniably the continuing trends of overconsumption of
the 2 limbs. This procedure results in the greatest weight loss food and decreased physical activity level over the past several
(64% of excess weight) along with resolution of diabetes (ap- decades are the proximal causes of the unrelenting increase in
proximately 95%) and other comorbidities. Unfortunately, a the prevalence of overweight and obesity globally. However,
recent prospective comparison found no advantage of this pro- the sociocultural and socioeconomic milieus within each coun-
cedure over the Roux-en-Y in the treatment of hypertension.59 try or local community can moderate these environmental
Regardless of the surgical procedure a multidisciplinary weight drivers and to some degree help reverse these proximal causes of
management team is required for assessment, selection of obesity.
proper candidates, pre- and long-term postoperative follow-up Successful approaches to tackling the obesity epidemic will
and management. require a comprehensive, multifaceted framework that inte-
grates population health, public health, and personal health
intervention strategies. Interventions aimed at reversing the
Management of Obesity-Related Hypertension in obesogenic environment will have the biggest impact. How-
Overweight and Obese Adolescents ever, in order to achieve these, governments at all levels must be
Health behaviour modification remains the cornerstone for persuaded to enact policies that facilitate the cooperation of
the treatment of overweight and obese adolescents with hyper- consumers, public and private sectors, nongovernmental orga-
tension and related metabolic comorbidities. However, no nizations, and various industries (food, service, transportation,
consistent protocols are available on such interventions and few and building, etc) in the promotion of higher levels of physical
published randomized trials report on BP lowering. With a activity and the consumption of healthy food choices in a man-
1-year training program of physical activity, nutrition, and be- ner which makes these the easy choices. Policy-led interven-
haviour therapy, SBP and DBP were lowered by 7 and 2 mm tions are more likely to change the population environments
Hg respectively.60 A shorter term study reported greater BP systematically and these population-wide effects are more likely
reduction by 14 and 9 mm Hg (SBP and DBP) after only 20 to be sustainable and longer lasting. One such example is a
weeks of lifestyle training.61 country-wide sodium reduction strategy. We have compelling
The efficacy and safety and of pharmacotherapy and surgi- evidence that high sodium intake contributes to the develop-
cal interventions for obesity treatment in children is limited. ment of hypertension and that reducing dietary intake by 3 g/d
Nguyen and Lau 331
Obesity and Hypertension

could greatly decrease new cases of heart disease and stroke, and References
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D.C.W.L. has received research funding, honoraria/
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