obesity and hypertension - easo · 2020. 12. 11. · (95% ci, 5.93 to 2.95) and a significant...
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![Page 1: Obesity and Hypertension - EASO · 2020. 12. 11. · (95% CI, 5.93 to 2.95) and a significant reduction in DBP of 3.57 mm Hg (95% CI, 4.88 to 2.25). When expressed per kilogram of](https://reader036.vdocuments.site/reader036/viewer/2022081623/613fca0fb44ffa75b8047384/html5/thumbnails/1.jpg)
ObesityandHypertensionDror Dicker MD, Internal Medicine D & Obesity Clinic Hasharon Hospital-Rabin Medical CenterSackler School Of Medicine Tel Aviv University, Israel.Co-Chair Obesity Management Task Force, EASO
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• John works as an accountant in a big company
• He is married with 2 children and he loves to cook for his family
• John is a former smoker who has been diagnosed with hypertension (5 years ago) and Type 2 Diabetes (4 years ago)
• 1 year ago he had acute coronary event and stent implantation in his LAD artery
• Lately he complains on effort dyspnoea
• His BMI is 35 kg/m2, latest HbA1c is 8.5% and his latest eGFR was 85mL/min/1.73 m2
• John is taking an ACE inhibitor for his blood pressure
• He is on metformin 1 g twice daily and sitagliptin 100 mg once daily.
Case Study : John, uncontrolled on dual therapy
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Obesity Hypertension - epidemiology
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Relative risk of hypertension for a five-unit increment in body mass index
Jayedi A, obesity reviews, 2018
• Fifty-seven prospective cohort studies were included
• 1.49 (95% [CI]: 1.41, 1.58;) for a five-unitincrement in body mass index.
• 1.16 (95%CI:1.09, 1.23;) for weight gain equal to a one-unit increment in BMI
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Mechanisms by which obesity induces hypertension
HallJEet.al,Circulation Res 2015
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Schematic of candidate mechanisms of leptin-induced hypertension in men and women
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weight loss effective in lowering BP in the long run
Life Style
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An average net weight reduction of 5.1 kg by means of energy restriction, increased physical activity, or the combined intervention was associated with a significant reduction in SBP of 4.44 mm Hg (95% CI, 5.93 to 2.95) and a significant reduction in DBP of 3.57 mm Hg (95% CI, 4.88 to 2.25). When expressed per kilogram of weight loss, reductions in SBP and DBP were 1.05 mm Hg (95% CI, 1.43 to 0.66) and 0.92 mm Hg (95% CI, 1.28 to 0.55) Respectively
Influence of Weight Reduction on Blood Pressure A Meta-Analysis of Randomized Controlled Trials
Neter JE. Hypertension. 2003
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Long-Term Weight Loss and Changes in Blood Pressure: Results of the Trials of Hypertension Prevention, Phase II
• individual counseling session, followed by 14 weekly group meetings
• After this 14-week-six biweekly group meetings and then monthly group meetings.
• It was suggested that men not consume less than 1500kcal/d and women not less than 1200 kcal/d.
• physical activity goal was 30 to 45 minutes per day, four to five days per week.
StevensVJ,AnnInternMed . 2001
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Long-Term Weight Loss and Changes in Blood Pressure: Results of the Trials of Hypertension Prevention, Phase II
StevensVJ,AnnInternMed . 2001
-8.8 kg
-2.6 kg -0.1 kg 2.6 kg 7.3 kg
Di Sy
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118
119
120
121
122
123
124
125
Baseline Year 1 Year 2 Year 3
Syst
olic
blo
od p
ress
ure
(mm
Hg)
Placebo Metformin Intensive lifestyle intervention
Intensive Lifestyle Intervention Reduces Blood Pressure, Diabetes Prevention Program(N=3234)
29 3033
39
3033
35
40
3026
29 29
05
1015202530354045
Baseline Year 1 Year 2 Year 3
Patie
nts
(%)
PlaceboMetforminIntensive lifestyle intervention
• BloodPressureChange • HypertensionPrevalence
DPP Research Group. Diabetes Care. 2005
P<0.001
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Changes in Weight, Physical Fitness and Blood Pressure during 10 Years of Follow-up in Look AHEAD.
Wing RR, NEJM, 2013
The difference in cardiovascular risk factors between intervention groups diminished over time, with hemoglobin A1c and systolic blood pressure showing the most sustained differences
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weight loss effective in lowering BP in the long run
Pharmacotherapy
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SCALE Obesity and Prediabetes: Trial design
Inclusion criteria:• BMI: ≥30 kg/m2, or ≥27 kg/m2 + comorbidities
• Stable body weight, and preceding failed dietary effort
0.6 mg1.2 mg
1.8 mg2.4 mg
16040–2Week
Screening
Liraglutide 3.0 mg/day
Placebo
Randomisation2:1 (liraglutide:placebo)
Dose escalation
56
End oftrial
68
Liraglutide 3.0 mg/day
Placebo
Liraglutide 3.0 mg/day
Placebo
Withoutprediabetes
With Prediabetes
0.6 mg1.2 mg
1.8 mg2.4 mg Off-drug
follow-up
172
All arms included lifestyle intervention: −500 kcal/day hypocaloric diet + 150 min/week increased physical activity
Off-drug follow-up
70
End oftreatment
Pi-Sunyer et al. NEJM 2015;373:11–22.
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SCALE Obesity and Prediabetes – Weight Loss
leRouxCW,Lancet2017
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SCALE Obesity and Prediabetes – Systolic Blood Pressure
leRouxCW,Lancet2017
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SCALE Obesity and Prediabetes – Diastolic Blood Pressure
leRouxCW,Lancet2017
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Gutzwiller etal,JCEM2004
Urinevolume
7006005004003002001000
Volu
me
(ml/1
80 m
in)
Placebo GLP-1
Urine osmolality
Excretion of sodium
8007006005004003002001000
Osm
olal
ity (m
osm
ol/l)
Placebo GLP-1
2.82.42.01.61.20.80.40
Fe N
a+(%
)
Placebo GLP-1
Fractional excretion of
sodium
160140120100806040200
Na+
excr
etio
n (m
mol
/180
min
)
Placebo GLP-1GLP-1
0.375 pmol/kg/min
1.5 pmol/kg/min
p < 0.001
p < 0.001p < 0.002
GLP-1 Increases Urine Volume and Sodium Excretion in Healthy Subjects
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Glp-1A Effects on Hypertension
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Pharmacological treatment of obesity-induced hypertension
Kotsis V et al Journal of Hypertension 2018
4. Lorcaserin 10 mg
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Pharmacological treatment of obesity-induced diabetes
Kotsis V et al Journal of Hypertension 2018
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weight loss effective in lowering BP in the long run
Bariatric Surgery
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Bariatric Surgery
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RecoveryfromDiabetes,LipidDisturbances,Hypertension,andHyperuricemiaover2and10YearsinSurgicallyTreatedSubjectsandTheirObeseControls
Sjostrom,L.etal.NEngl JMed2004;351:2683-2693
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Mean Percent Change in Body Weight from Baseline to Years 2,6, and 12 in the Surgery Group
Adams TD, NEJM 2017
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Unadjusted Mean Baseline and 12-Year Follow-up Values for Clinical Variables, According to Study Group
Adams TD, NEJM 2017
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What are the Mechanisms that improve blood pressure Control After Bariatric Surgery ?– Weight loss– volume and urinary sodium excretion– Increase in Gut Hormone (GLP-1)
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Summery Life Style • Weight Loss is effective in lowering Blood Pressure in the long run !
– Weight loss is maintained– Regular Physical activity (200-300 min/w)
Pharmacotherapy Weight Loss is effective in lowering Blood Pressure in the long run !– Using Anti Obesity Medication
• ( GLP-1, liraglutide)• Increasing ANP• volume and urinary sodium excretion &vasodilatation
• LorcaserinBariatric Surgery
Weight Loss is effective in lowering Blood Pressure in the long run !– Bariatric Surgery
• Weight loss• volume and urinary sodium excretion• Increase in Gut Hormone (GLP-1)
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