Obesity, Hypertension, and Bariatric Surgery

Obesity and hypertension: Obesity medicine association (OMA) clinical practice statement (CPS) 2023

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) provides an overview of the mechanisms and treatment of obesity and hypertension.

Methods

The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

Mechanisms contributing to obesity-related hypertension include unhealthful nutrition, physical inactivity, insulin resistance, increased sympathetic nervous system activity, renal dysfunction, vascular dysfunction, heart dysfunction, increased pancreatic insulin secretion, sleep apnea, and psychosocial stress. Adiposopathic factors that may contribute to hypertension include increased release of free fatty acids, increased leptin, decreased adiponectin, increased renin-angiotensin-aldosterone system activation, increased 11 beta-hydroxysteroid dehydrogenase type 1, reduced nitric oxide activity, and increased inflammation.

Conclusions

Increase in body fat is the most common cause of hypertension. Among patients with obesity and hypertension, weight reduction via healthful nutrition, physical activity, behavior modification, bariatric surgery, and anti-obesity medications mostly decrease blood pressure, with the greatest degree of weight reduction generally correlated with the greatest degree of blood pressure reduction.

Shorter History of Hypertension as a Predictor of Hypertension Remission after 3-years of Bariatric Surgery: Data from the GATEWAY Trial

BACKGROUND

Previous evidence explored predictors of hypertension (HTN) remission after bariatric but data are limited to observational studies and lack of ambulatory blood pressure monitoring (ABPM). This study was aimed to evaluate the rate of HTN remission after bariatric surgery using ABPM and to define predictors of mid-term HTN remission.

METHODS

We included patients enrolled in the surgical arm of the GATEWAY randomized trial. HTN remission was defined as controlled blood pressure (< 130 × 80 mmHg) evaluated by 24-h ABPM while no need of anti-hypertensive medications after 36 months. A multivariable logistic regression model was used to assess the predictors of HTN remission after 36 months.

RESULTS

46 patients submitted Roux-en-Y gastric bypass (RYGB). HTN remission occurred in 39% (n = 14 out of 36 patients with complete data at 36 months). Patients with HTN remission had shorter HTN history than no remission group (5.9 ± 5.5 vs. 12.5 ± 8.1 years; p = 0.01). The baseline insulin levels were lower in patients who presented HTN remission, although not statistically significant (OR: 0.90; CI 95%: 0.80-0.99; p = 0.07). In the multivariate analysis, the HTN history (years) was the only independent predictor of HTN remission (OR: 0.85; 95% CI: 0.70-0.97; p = 0.04). Therefore, for each additional year of HTN history, the chance of HTN remission decreases by approximately 15% after RYGB.

CONCLUSION

After 3 years of RYGB, HTN remission defined by ABPM was common and independently associated with a shorter HTN history. These data underscore the need of early effective approach of obesity aiming greater impact in its comorbidities.

The Relationship between Metabolic Comorbidities and Post-Surgical Weight Loss Outcomes in Adolescents Undergoing Laparoscopic Sleeve Gastrectomy

INTRODUCTION

Little is known about the relationship between metabolic factors and weight loss success in adolescents undergoing bariatric surgery.

METHODS

The objective of this study was to assess if baseline metabolic characteristics associate with weight loss in adolescents undergoing laparoscopic sleeve gastrectomy. A retrospective study was conducted in a comprehensive adolescent bariatric surgery center of 151 subjects (34 male, 117 female). Anthropometric measurements and metabolic factors including blood pressure, fasting glucose, hemoglobin A1c (HbA1c), metabolic syndrome (MeS), liver function, triglycerides, and waist circumference were collected at one pre-surgical visit and at 6- and/or 12-month post-laparoscopic sleeve gastrectomy. Weight loss was compared between subjects with normal or abnormal baseline metabolic factors. Absolute BMI change was used to measure successful weight loss.

RESULTS

Higher baseline systolic blood pressure (SBP) was associated with greater weight loss as measured by body mass index (BMI) change and BMI standard deviation score (BMI-SDS) change at 6 and 12 months. Those patients in the 6-month follow-up group with an abnormal HbA1c at baseline had significantly more weight loss as measured by BMI-SDS. None of the other parameters, including fasting glucose, MeS, liver function, triglycerides, and waist circumference showed a predictive relationship.

CONCLUSION

Elevated SBP and HbA1c in adolescents with morbid obesity may reflect a population more likely to achieve successful weight loss and, thus, may be a good target for bariatric surgery, specifically laparoscopic sleeve gastrectomy, as an intervention for severe obesity. An assessment of behavioral differences in patients with and without elevated BP and HbA1c might explain the mechanism for the improved weight loss.

Inflammatory and metabolic markers and comorbidities remission following sleeve gastrectomy: A single center one-year cohort study

BACKGROUND AND AIM

Obesity is a global concern with several health-related complications. Bariatric surgeries are major treatment options in patients with obesity and other comorbidities. This study aims to investigate the effects of sleeve gastrectomy on metabolic indexes, hyperechogenic liver changes, inflammatory state, diabetes, and other obesity-related comorbidities remission after the sleeve gastrectomy.

METHODS

This prospective study was conducted on patients with obesity candidates for laparoscopic sleeve gastrectomy. Patients were followed for one year after the surgery. Comorbidities, metabolic and inflammatory parameters were assessed before and one- year after the surgery.

RESULTS

137 patients (16 males, 44 in the DM group) underwent sleeve gastrectomy. One year after the study, obesity-related comorbidities improved significantly; diabetes had complete remission in 22.7% and partial remission in 63.6% of patients. Hyper-cholesterolemia, hyper-triglyceridemia, and hyper-uricemia also improved in 45.6%, 91.2%, and 69% of the patients. Metabolic syndrome indexes improved in 17.5% of the patients. Also, the prevalence of hyperechogenic changes in the liver has declined from 21% before the surgery to 1.5% after that. Based on logistic regression analysis, increased levels of HbA1C reduced the chance of diabetes remission by 0.9%. In comparison, every unit of increased BMI before the surgery improved the case of diabetes remission by 16%.

CONCLUSION

Laparoscopic sleeve gastrectomy is a safe and effective treatment option in patients with obesity and diabetes. Laparoscopic sleeve gastrectomy alleviates BMI and insulin resistance and effectively improves other obesity-related comorbidities such as Hypercholesterolemia, hyper-triglyceridemia, hyper-uricemia, and hyperechogenic changes of the liver. HbA1C and BMI before the surgery are notable predictors of diabetes remission within the first year after the surgery.

Endoscopic management of obesity: Impact of endoscopic sleeve gastroplasty on weight loss and co-morbidities at six months and one year

INTRODUCTION

Endoscopic sleeve gastroplasty (ESG) is one of the new minimally invasive endoscopic treatments aimed at inducing weight loss. Its effectiveness in terms of weight loss is proven. Gastric volume reduction and delayed gastric emptying are the mechanisms that drive weight loss. However, potential benefits for co-morbidities in relation to weight loss after ESG are still being investigated. This study aims to evaluate the effect of ESG procedures on major obesity-associated co-morbidities, and on some biological parameters.

PATIENTS AND METHODS

This is a series of consecutive cases from a prospective observational study carried out in a specialized center that follows a standardized care pathway for the multimodal management of obesity. Patients who have undergone ESG with endoscopic and laboratory follow-up at six and twelve months after this intervention were included in the study. Prospectively recorded data on weight loss, co-morbidities and laboratory parameters at six and twelve months after surgery was analyzed retrospectively. Changes in body mass index (BMI), absolute weight loss (AWL), percent of excess weight loss (%EWL) and percent total weight loss (%TWL) were assessed at six and twelve months. Reduction in various obesity-related co-morbidities (arterial hypertension [AHT], type 2 diabetes mellitus [T2DM], gastroesophageal reflux disease [GERD], obstructive sleep apnea syndrome [OSAS] and dyslipidemia was also evaluated at six and twelve months. Changes in blood glucose, liver function tests and lipid blood tests were also analyzed at six and twelve months.

RESULTS

From October 2016 to July 2021, 99 of the 227 patients who underwent ESG in our unit (43.6%) subsequently underwent a complete endoscopic and laboratory follow-up at six and twelve months. The initial BMI was 42.7±7.8kg/m² and age was 45±12.7 years. Seventy-four patients (74.8%) were female. Total weight loss (%TWL) and excess weight loss (%EWL) were 16.6±7.4% and 43.3±21.2%, respectively, at six months, 16.6±9.6% and 42.9±25.6%, respectively, at one year. At six and twelve month follow-up, a statistically significant reduction was observed for the rates of T2DM (30.8 and 32.7%), hypertension (18.4 and 22.1%), GERD (28 and 25.7%), OSAS (15.8 and 25.5%) and dyslipidemia (69.2 and 77.2%) (P<0.001). A statistically significant difference was found in the reduction in blood glucose between the pre-operative period and six months post-operatively (P<0.01) and between the pre-operative period and twelve months post-operatively (P<0.01). The reduction in triglycerides and total cholesterol between the pre-operative values and at six months was statistically significant (P<0.01) as was the reduction at twelve months (P<0.01) (P=0.017). For liver function tests, the reduction in AST was statistically significant at six and twelve months after ESG (P=0.048) (P=0.048) as was ALT (P<0.01) (P<0.01) respectively. From October 2016 to July 2021, of the 227 patients who underwent ESG, 99 (43.6%) had follow-up gastro-duodenoscopy at 6 and 12 months. %TWL and %EWL were respectively 16.6±7.4% and 43.3%±21.2 at 6 months, 16.6±9.6% and 42.9±25.6% at one year. Statistically significant reduction rates at 6 and 12 months were observed in T2DM (30.8 and 32.7%), AHT (18.4 and 22.1%), GERD (28 and 25.7%), OSAS (15.8 and 25.5%) and dyslipidemia (69.2 and 77.2%) (P<0.001). Moreover, glycemic levels were statistically significantly reduced between the pre-operative period and 6 months post-operative (1.11±0.22mg/L vs. 1.01±0.17mg/L, P<0.01), and between the pre-operative period and 12 months post-operative (1.11±0.22mg/L vs. 1.06±0.32mg/L, P<0.01). A statistically significant reduction was also observed in triglycerides and total cholesterol levels at 6 months (1.52±0.74mmol/L vs. 1.14±0.52mmol/L, P<0.01) (1.94±0.4mmol/L vs. 1.85±0.36mmol/L, P<0.01) and at 12 months (1.52±0.74mmol/L vs. 1.18±0.67mmol/L, P<0.01) (1.94±0.4mmol/L vs. 1.82±0.39mmol/L, P=0.017) and in AST (27.2±11.7 IU/L vs. 23.7 IU/L; P=0.048) (27.2±11.7 IU/L vs. 24.7±14.65 IU/L, P=0.048) and ALAT levels (34±21.32 IU/L vs. 22.3±10.4 IU/L, P<0.01 and 34±21.32 IU/L vs. 27.07±25 IU/L, P<0.01) at 6 and 12 months after ESG, respectively.

CONCLUSION

ESG is a well-tolerated and safe surgical procedure that is effective in terms of weight loss and reduction of obesity-related co-morbidities at six months and one year. This procedure could thus be adopted on a broader clinical scale and be more widely promoted as an effective treatment for morbid obesity.

Comparison of hypertension remission and relapse after sleeve gastrectomy and one-anastomosis gastric bypass: a prospective cohort study

This study aimed to assess the remission and relapse of hypertension (HTN) in hypertensive individuals who underwent sleeve gastrectomy (SG) and one-anastomosis gastric bypass (OAGB) and identify the predictors of HTN remission and relapse following bariatric surgery. A prospective cohort study with a follow-up of 3 years was conducted on severely obese patients between 2013 and 2018. Hypertension remission was defined as the normalization of blood pressure (BP) with the discontinuation of medical treatment, and HTN relapse was defined as the need for the onset of antihypertensive drugs or the occurrence of BP impairment. A total of 787 hypertensive patients were included in this study. The cumulative incidence of HTN remission and relapse were 83.9% (95% CI: 81.6-86.5) and 31.4% (95% CI: 25.6-38.2), respectively. Remission and relapse were not significantly different among the patients undergoing either surgery (SG or OAGB). A higher remission rate was linked to a younger age and the use of fewer antihypertensive medications pre-operation. However, failure to successfully lose weight during the first year postoperative and weight regain predicted a higher risk of HTN relapse after 3 years. Following bariatric surgery, BP drops initially but then gradually rises. These alterations are responsible for about 31% relapse after 3 years in those who initially achieve remission. Patients who are younger and use less antihypertensive medications before surgery may benefit the most from bariatric surgery in terms of HTN. First-year successful weight loss and control of weight regain may prevent HTN relapse in the following years.

Bariatric surgeries: Outcome throughout an annum at a specialist center in Malaysia

INTRODUCTION

Malaysia has the highest number of obese and overweight individuals in South-east Asia. The 2019 National Health & Morbidity survey found 50.1% of Malaysians to be overweight or obese with 30.4% being overweight and 19.7% being obese. This has led to the high rise of the bariatric surgeries demand and needs within the nation.

AIM & OBJECTIVES

To assess the level of fasting blood sugar (FBS), systolic, diastolic blood pressure, stop BANG score for obstructive sleep apnoea (OSA) and BMI (Body Mass Index) for the patients before and after bariatric surgeries (sleeve/gastric bypass) for a one year follow up period.

MATERIAL & METHODS

The study was conducted among 1000 patients who underwent a single weight reduction surgery (sleeve/gastric bypass) by a single surgeon at the Cengild Medical Centre between January 2019 to January 2020. They were followed up for a one-year period through recording the parameters of fasting blood sugar (FBS), systolic, diastolic blood pressure, stop BANG score for obstructive sleep apnoea (OSA) and BMI (Body Mass Index). Study was conducted using universal sampling including all subjects visited the centre and a written consent was obtained from each participant. Descriptive statistics with mean was used and paired t-test was used for comparison and test the difference. The STOP-BANG acronym stands for: Snoring history, Tired during the day, Observed stop breathing while sleep, High blood pressure, BMI more than 35 kg/m2, Age more than 50 years, Neck circumference more than 40 cm and male Gender.

RESULTS

The mean age of patients was 38 years old. Mean FBS for the patients one month before the operation was 10.42 mmol/L and 5.84 three months post procedure. The systolic blood pressure one month before the operation and 3 months after was 139.81 mmHg and 123.79 mmHg, while diastolic blood pressure was 86.84 mmHg and 81.07 mmHg respectively. BMI was reduced from 39.69 to 27.99 after one year from the weight reduction operation. All the above parameters showed a significant reduction between one-month pre operation as compared to 3 months and 12 months post operation and that improved the health parameters of the patients significantly.

CONCLUSION

The weight reduction operations showed a significant reduction in the FBS, blood pressure, OSA scores and BMI at 3, 12 months after the operation These patients had better overall health after the significant reduction in these parameters.

Alterations in Fecal Short-Chain Fatty Acids after Bariatric Surgery: Relationship with Dietary Intake and Weight Loss

Bariatric surgery is associated with weight loss attributed to reduced caloric intake, mechanical changes, and alterations in gut hormones. However, some studies have suggested a heightened incidence of colorectal cancer (CRC) has been associated with bariatric surgery, emphasizing the importance of identifying mechanisms of risk. The objective of this study was to determine if bariatric surgery is associated with decreases in fecal short-chain fatty acids (SCFA), a group of bacterial metabolites of fiber. Fecal samples (n = 22) were collected pre- (~6 weeks) and post-bariatric surgery (~4 months) in patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy. SCFA levels were quantified using liquid chromatography/mass spectrometry. Dietary intake was quantified using 24-h dietary recalls. Using an aggregate variable, straight SCFAs significantly decreased by 27% from pre- to post-surgery, specifically acetate, propionate, butyrate, and valerate. Pre-surgery weight was inversely associated with butyrate, with no association remaining post-surgery. Multiple food groups were positively (sugars, milk, and red and orange vegetables) and inversely (animal protein) associated with SCFA levels. Our results suggest a potential mechanism linking dietary intake and SCFA levels with CRC risk post-bariatric surgery with implications for interventions to increase SCFA levels.

Cytochrome P450 epoxygenase-derived EPA and DHA oxylipins 17,18-epoxyeicosatetraenoic acid and 19,20-epoxydocosapentaenoic acid promote BAT thermogenesis and WAT browning through the GPR120-AMPKα signaling pathway

The mechanisms whereby fish oil rich in EPA and DHA promotes BAT thermogenesis and WAT browning are not fully understood. Thus, this study aimed to investigate the effects of cytochrome P450 (CYP) epoxygenase-derived EPA and DHA oxylipins 17,18-EpETE and 19,20-EpDPE on BAT thermogenesis and WAT browning and explore the underlying mechanism. Stromal vascular cells (SVCs) were subjected to 17,18-EpETE or 19,20-EpDPE treatment and mice were treated with the CYP epoxygenase inhibitor, the thermogenic marker genes were detected and the involvement of GPR120 and AMPKα were assessed. The in vitro results indicated that 17,18-EpETE and 19,20-EpDPE induced brown and beige adipocyte thermogenesis, with increased expression of thermogenic marker gene UCP1 in differentiated SVCs. Meanwhile, the expression of GPR120 and phosphorylation of AMPKα were increased in response to these two oxylipins. However, the inhibition of GPR120 and AMPKα inhibited the promotion of adipocyte thermogenesis. In addition, in the presence of CYP epoxygenase inhibitor MS-PPOH, EPA and DHA had no effect on increasing UCP1 expression in differentiated SVCs. Consistent with the in vitro results, the in vivo findings demonstrated that fish oil had no body fat-lowering effects and no effects on enhancing energy metabolism, iBAT thermogenesis and iWAT browning in mice fed HFD after intraperitoneal injection of CYP epoxygenase inhibitor SKF-525A. Moreover, fish oil had no effect on the elevation of GPR120 expression and activation of AMPKα in iBAT and iWAT in mice fed HFD after intraperitoneal injection of SKF-525A. In summary, our results showed that CYP epoxygenase-derived EPA and DHA oxylipins 17,18-EpETE and 19,20-EpDPE promoted BAT thermogenesis and WAT browning through the GPR120-AMPKα signaling pathway, which might contribute to the thermogenic and anti-obesity effects of fish oil.

Arterial Hypertension in Morbid Obesity after Bariatric Surgery: Five Years of Follow-Up, a Before-And-After Study

BACKGROUND

Arterial hypertension (HTN) is common among morbidly obese patients undergoing bariatric surgery. The aim of this study is to analyse the prevalence and evolution of HTN and weight loss in patients suffering from morbid obesity before and after bariatric surgery, during a follow-up period of five years.

METHODS

A before-and-after study was carried out on severely obese patients undergoing Laparoscopic Roux-En-Y Gastric Bypass (LRYGB). Criteria for HTN diagnosis were current treatment with antihypertensive agents and/or systolic blood pressure (SBP) > 140 mmHg and/or diastolic (DBP) > 90 mmHg. HTN remission was defined as normalisation of blood pressure (BP) maintained after discontinuation of medical treatment, and HTN recurrence was considered when HTN diagnostic criteria reappeared after remission. Weight loss during the study period was evaluated for each patient, calculating excess weight loss percentage (% EWL) and BMI loss percentage (% BMIL) with reference to the baseline value.

RESULTS

A total of 273 patients were included in the study. HTN was present in 48.2%; 29.4% of hypertensive patients showed HTN remission two years after the surgical procedure, 30.3% of them had relapsed at five years.

CONCLUSION

LRYGB in obese patients is associated with a remission of HTN, and no weight loss differences were observed between the group of patients showing HTN remission at two years and the group who did not. However, differences were observed after the second follow-up year, with an increased weight loss in the remission group, which could indicate that sustained weight loss favours the control of HTN.

SOCS3 Gene Polymorphism and Hypertension Susceptibility in Chinese Population: A Two-Center Case-Control Study

Endothelial inflammation and vascular damage are essential risk factors contributing to hypertension. Suppressor of cytokine signaling 3 (SOCS3) is involved in the regulation of multiple inflammatory pathways. A large number of studies have shown that the anti-inflammatory effect of SOCS3 in hypertension, obesity, and allergic reactions has brought more insights into the inhibition of inflammation. Therefore, we selected a tagSNP of SOCS3 (rs8064821) to investigate whether they are contributing to the risk of hypertension in the Chinese population. In total, 532 patients with hypertension and 569 healthy controls were enrolled for two central of China. SOCS3 rs8064821 C>A polymorphism was genotyped using TaqMan assay. SOCS3 rs8064821 CA genotype was associated with an increased risk of hypertension (OR = 1.821, 95%CI = 1.276-2.600, P = 0.001). Rs8064821 A allele was associated with higher SOCS3 mRNA level in PBMCs from healthy donors. SOCS3 rs8064821 C>A polymorphism may contribute to the risk of hypertension in the Chinese population by regulating the expression of SOCS3.

Transcription Coactivator BCL3 Acts as a Potential Regulator of Lipid Metabolism Through the Effects on Inflammation

Background and Purpose

Transcriptional coactivator B-cell lymphoma-3 (BCL3) is a member of the IκB family of NF-κB inhibitors and regulates the activity of the NF-κB pathway. However, the relationship between BCL3 and lipid metabolism remains unclear. The present study investigates the effects of BCL3 in immune and metabolism in obese mice.

Animals and Methods

Construct Bcl3-KO mice through CRISPR/Cas9 technology. Obesity model was induced in Bcl3-KO mice by feeding a high-fat diet for 16 weeks, and some metabolic-related indicators were analysed.

Results

The results showed that the KO mice gained significantly less body weight on a high fat diet without a change in food intake. There was significant improvement in hepatic steatosis and adipose tissue hypertrophy in KO mice. The expression of SREBP1 and its downstream fatty acid synthetase FAS and ACC were down-regulated in KO mice, and the inflammation in adipose tissue and liver was further reduced.

Conclusion

These results suggest that BCL3 may be a novel factor in regulating lipid metabolism in the development of obesity.

Associations of exposure to secondhand smoke with hypertension risk and blood pressure values in adults

Background

The effects of environmental chemical exposure on blood pressure (BP) have been confirmed, but the association between exposure to secondhand smoke (SHS) and hypertension risk and BP in the general population remains unknown.

Methods

Cross-sectional associations between SHS exposure and hypertension risk and BP values were evaluated using data for subjects who participated in the National Health and Nutrition Examination Survey (NHANES), 1999–2016. Logistic regression and linear regression were performed after adjusting for age, sex, race, alcohol consumption, poverty-to-income ratio (PIR), body mass index (BMI), estimated glomerular filtration rate, physical activity, diabetes, cardiovascular disease, and NHANES cycle. Restricted cubic spline models were created to display the potential nonlinear association between SHS and BP levels.

Results

Higher risk of hypertension was found at the highest SHS concentrations (OR = 1.13, 95% CI 1.04, 1.24, P for trend = 0.007). Additionally, SHS exposure had a strong positive association with systolic blood pressure (SBP) but was negatively associated with diastolic blood pressure (DBP). Furthermore, the nonlinear model result showed a significant association between SHS and SBP (P = 0.017); however, the nonlinear model result was not significant for SHS or DBP.

Conclusions

Our results suggest a potential association between high SHS exposure and the risk of hypertension. Further research is needed to elucidate the underlying mechanisms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12199-021-01009-0.

Obesity, kidney dysfunction, and inflammation: interactions in hypertension

Obesity contributes 65-75% of the risk for human primary (essential) hypertension (HT) which is a major driver of cardiovascular and kidney diseases. Kidney dysfunction, associated with increased renal sodium reabsorption and compensatory glomerular hyperfiltration, plays a key role in initiating obesity-HT and target organ injury. Mediators of kidney dysfunction and increased blood pressure include (i) elevated renal sympathetic nerve activity (RSNA); (ii) increased antinatriuretic hormones such as angiotensin II and aldosterone; (iii) relative deficiency of natriuretic hormones; (iv) renal compression by fat in and around the kidneys; and (v) activation of innate and adaptive immune cells that invade tissues throughout the body, producing inflammatory cytokines/chemokines that contribute to vascular and target organ injury, and exacerbate HT. These neurohormonal, renal, and inflammatory mechanisms of obesity-HT are interdependent. For example, excess adiposity increases the adipocyte-derived cytokine leptin which increases RSNA by stimulating the central nervous system proopiomelanocortin-melanocortin 4 receptor pathway. Excess visceral, perirenal and renal sinus fat compress the kidneys which, along with increased RSNA, contribute to renin-angiotensin-aldosterone system activation, although obesity may also activate mineralocorticoid receptors independent of aldosterone. Prolonged obesity, HT, metabolic abnormalities, and inflammation cause progressive renal injury, making HT more resistant to therapy and often requiring multiple antihypertensive drugs and concurrent treatment of dyslipidaemia, insulin resistance, diabetes, and inflammation. More effective anti-obesity drugs are needed to prevent the cascade of cardiorenal, metabolic, and immune disorders that threaten to overwhelm health care systems as obesity prevalence continues to increase.