Dr. Sharda Jain
Secretary General
Delhi Gynaecologist Forum

Obesity is one of the most visible, yet the most neglected, risk  factors contributing to the overall   burden  of disease worldwide. It is estimated that at least 1-1 billion adults and 10% 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 types of cancer all leading to a decreased life.

The main cause of the obesity epidemic is  clear; overeating , especially that of foods, which are rich in fats, extracted sugar, or refined starches. This linked to a progressive decline in physical activity results in an imbalance of the 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 gynaecoloist and not cardiologist but in last two years, 5 people, dear to me  lost their life just  because they neglected their health.  I decided to plead t public to lead a public movement against obesity and hypertension.

47 years  hypertensive and obese women,  left treatment during  Navratri days – develops  severe headache – massive brain haemorrhage and  died after remaining on  ventilator for 10 days.

26 years old obese and hypertensive boy, only son of  parents, never bothered about his health, believed in fun, fun and 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.

56 years old, politician, not bothered about health and medication, died of sudden heart   attack, before he could reach hospital.

37 years old obese and hypertensive women, she bothered about every thing except herself, treatment was taken irregularly. She had sudden cardiac arrest in bus and died before she could reach her home.

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  untimely life.

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 attach 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’s condition. Secondary hypertension  indicate that the high blood pressure is a result of (i.e secondary to) another condition , such as kidney disease or certain    tumors ( 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 “prehypertension and should not be  neglected.  “The American  Heart Association      class hypertension the silent killer. It’s an apt term. As a major cause of strokes, heart attacks,  and kidney disease, 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 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 area even in younger age groups. A community based sample in Kerala established that over half of all middle-aged individual 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 Indian’s have high blood pressure, but a significant number don’t know it. And as our population grows older, heavier and more sedentary, this silent epidemic is sure to grow and harm society.

Distinguishing primary vs, secondary hypertension
Once the  diagnosis of hypertension has been made it is  important to attempt to exclude or identify or identify reversible (secondary) causes. Over 90% 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 Epidemic 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 percent 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. Generally, risk estimate suggest that approximately 75 and 65 percent of the cases of hypertension in men and women, respectively, are directly attributable to an overweight condition and obesity.

Obesity and  hypertension – a killer combination
Organ damage can result early  from obesity hypertension combination . Elevated  blood pressure due to obesity can cause  long-term damage to the body’s vital organs and functions. This damage can occur to the heart and vacular 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   B P in obese hypertensive. 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 percent 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 ; odium 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 Antihypertensive Therapy
Many patients will not have their blood pressure controlled by one drug alone. As most  antihypertensive 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.

Antihypertensive for the obese?
Unfortunately, there is limited data on the safety and efficacy of common antihypertensives for the obese. The results  of most of the antihypertensive 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 5% or more  weight loss have a decline in blood pressure that correlates with the decline in weight. Moderate weight loss improves metabolic andcardiovascular risk factors and prevents the progression to type 2 diabetes.

The challenge for Anti-Obesity management is clear. The anti-obesity treatment need to be aggressive to help to  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 log-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, if you restrict diet  and do well  planed exercise regimen. Simply taking drugs does not help individuals.

In summary, obesity and hypertension have synergistic effects leaving the obese hypertensive patients at high risk for a hot 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.

Public movement should be started  in India about regular medical checkups, and awarding individuals and community with normal weights . Campaign should be built against “sweets” and community  should be awarded for not having   sweet shops in their neighbourhood.