Hypertensio

n and
Obesity
STANDARD OF CARE

Hypertension and Obesity

There is a clear relationship between hypertension and
obesity
Most people who are overweight or obese have
hypertension
Obesity puts one at higher risk of developing clinical
consequences of hypertension
Lifestyle modifications are recommended for both
obesity and hypertension
Loss of excess weight lowers blood pressure
There are no specific guidelines for treating
hypertension in the obese, general principles of

In the United States, all geographic racial and cultural subgroups

have increased cardiovascular risk with increased weight.
Fat distribution is a major risk factor; visceral fat mass carries a
higher association with increased cardiovascular disease than BMI
alone.
Upper body (central, visceral or apple shaped) is associated with
other cardiovascular risk factors (diabetes, dyslipidemia and
hypertension)
Peripheral (lower or pear shaped) obesity may not be a reliable
indicator of insulin resistance or increased early morbidity and
mortality.

Apple vs. Pear

shape
Central or upper body
obesity (apple shape) is
associated with increased
blood pressure.

Joint National Committee (JNC 8)

The Joint National Committee on the Prevention,
Detection, Evaluation and Treatment of High Blood
Pressure was formed in 1972 partnering with other
organizations.
Goal was to educate the public, providers and patients
regarding the health risks of high blood pressure and the
benefits of treatment and control of high blood pressure.
Standardized treatments were proposed
Downward trends of age-adjusted stroke mortality in the
U.S. was seen with this initiative
U.S. has one of the lowest mortality rates from stroke in
the world

Treatment: Lifestyle Modifications

Lifestyle Changes: An extremely important part of
therapy
Use the Dash (Dietary Approaches to Stop Hypertension)
diet, rich in fruits, vegetables, low-fat dairy products,
low in saturated and total fats. Reduce sodium intake to
less than 2.4 grams per day
Weight loss
At least 30 minutes of aerobic activity most days
Limit alcohol to 2 drinks daily in men and 1 drink daily in
women. (1 drink constitutes 12 ounces of beer, 5
ounces of wine, or 1.5 ounces of 80-proof liquor).

Treatment Recommendations: Diet and

Weight Loss
Weight loss therapy should be initiated for every
overweight or obese patient with hypertension
The initial weight loss goal should be 10-15% from
baseline which will improve blood pressure and other
comorbidities.
Optimal weight usually takes at least 6 months to
achieve; 1-2 pounds per week is recommended
Thoroughly evaluate the usual diet, food preferences
and eating habits of the patient
Consider referring the patient to a dietitian or

Treatment recommendations: Psychosocial

and Behavior Modification
Assess the patients' attitude toward weight loss, are
they ready? Are they capable of increasing physical
activity?
Recommend the buddy system, exercise and weight loss
with a spouse, friend, co-worker, etc.
Stress importance of behavior modification, develop an
out with the old, in with the new attitude towards
habits. Primary focus is self control to change habits.
Discuss gradual, permanent changes in diet and
exercise such as changing eating habits, increasing
physical activity, change attitudes, build a support
system and become educated in nutrition.

Treatment Recommendations: Dietary

changes
Hypocaloric diet: may be low in fat but the most crucial
part is a decrease in calories.
Nutritional plans should be individualized and long term
for weight loss and maintenance
Encourage reduction in high fat foods and sugar use
Encourage increased fiber
Watch portion size
Enlist the help of a dietician

Treatment Recommendations: Physical

Activity
Exercise is crucial for weight loss and maintenance
Improves blood pressure control and insulin sensitivity
Obese patients need a decrease in calories and an
increase in energy expenditure
Start slow and for short times at least 5 days/week from
the beginning
Low intensity working toward increased intensity
Goal: 5-7 days per week for 30 minutes. May be divided
if necessary.

Additional guidance
Weight loss medications may be necessary if a six
month trial of diet, exercise and behavioral therapy has
been successful
Consider referral to medical bariatrician
For high risk obese individuals (BMI > 40% or BMI >
35% with significant co-morbidities or adverse health
conditions), surgical weight loss treatment may need to
be considered.

Blood Pressure Management

Sometimes even with weight loss blood pressure does not return to
normal. For these patients, antihypertensive drug treatment must be
initiated or maintained.
New guidelines were released by JNC 8 in 2013, some of which are:
In patients 60 years or older who do not have diabetes or chronic kidney
disease, the goal blood pressure level is now <150/90 mm Hg.
In patients 18 to 59 years of age without major comorbidities, and in patients
60 years or older who have diabetes, chronic kidney disease (CKD), or both
conditions, the new goal blood pressure level is <140/90 mm Hg.
First-line and later-line treatments should now be limited to 4 classes of
medications: thiazide-type diuretics, calcium channel blockers (CCBs), ACE
inhibitors, and ARBs.

Blood Pressure Management in the Obese

General Management for the obese are not different
from that of the non-obese, but keep the following in
mind:
Diuretics may be required in higher doses, however,
higher doses tend to increase blood sugar and decrease
potassium in high doses
A preferred treatment is a lower dose of diuretics with
and ACE inhibitor or an angiotensin receptor blocker
(ARB)
ACE or ARB are renal protective, reverse left ventricular
hypertrophy and improve insulin sensitivity, all useful in
obese patients.