Obesity-hypertension: the effects on cardiovascular and renal systems

The Burden of Hypertension in HIV-Infected Adults on Retroviral Therapy in Masvingo Province, Zimbabwe: A Retrospective Cohort Study

Background and objective The global HIV epidemic has evolved in the past 30 years with a decline in mortality and morbidity and improved survival since the introduction of antiretroviral therapy (ART). However, this has brought on new challenges through the emergence of non-communicable disease (NCD) as a pandemic at par with, if not more serious than, HIV, and patients well maintained on ART are now faced with the increased risk of developing NCDs such as hypertension, which also require lifelong therapy. This study was designed to determine the burden of hypertension in patients under HIV care in Masvingo province, Zimbabwe. Methods A retrospective cohort study was conducted in six districts of Masvingo province based on the data collected from the electronic Patient Monitoring System (ePMS), along with an analysis of secondary data. Of the 94,821 records gathered, 877 met the inclusion criteria to be included in the study. Data were analyzed using Microsoft Excel and Stata statistical software and statistical analysis was performed using the χ2 test. Results The study revealed a hypertension prevalence of 7.64% among the 877 patients analyzed and the independent risk factors for the development of hypertension were determined to be the age of patients, with a one-year increase in age resulting in an 8% increase in the risk of developing hypertension, and the duration on ART, with a one-year increase on ART duration increasing the risk of hypertension by 27%, and an increase in BMI by a factor of 1 increasing the risk of getting hypertension by 9%. Conclusion Our findings showed that there are patients who have both hypertension and HIV on ART care, and they would need to be managed for both. There is a need for improved data collection of important variables that improve the quality of care of clients. Clinical management of HIV needs to evolve with the evolving needs of patients and NCD care has to be factored in.

Associations between triglyceride-glucose index and different hypertension subtypes: A population-based study in China

Background

Abnormal glycolipid metabolism plays a crucial role in hypertension. While an elevated triglyceride-glucose (TyG) index has been recognized as a risk factor for developing hypertension, the associations between the TyG index and different hypertension subtypes, namely, isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and systolic-diastolic hypertension (SDH), remain unclear. This study was designed to investigate the associations between the TyG index and hypertension subtypes in a general Chinese population.

Materials and methods

In a sample of 16,793 participants from Shandong Province, China, multivariate logistic regression analyses were performed to examine the associations between the TyG index and different hypertension subtypes. Loess smooth curves were fitted to visualize the trends. Stratified analyses were conducted to further assess the potential interactions in the associations between the TyG index and different hypertension subtypes.

Results

A higher TyG index was associated with an increased odds of having IDH (OR = 2.94, 95% CI: 1.66–5.23) and SDH (OR = 1.82, 95% CI: 1.33–2.49), whereas no apparent relationship was observed between TyG index and ISH. With respect to sex, the effect of TyG index on having IDH and SDH was significant in women, but not in men. Participants with lower lipid profiles and glucose levels demonstrated a stronger strength of association between the TyG index and IDH as compared with the TyG index-SDH association. Stratified analysis showed that participants with a higher TyG index were more than 3 times more likely to have IDH and SDH among persons aged 18–42 years. Significant interactions were observed between TyG index and sex, age, and high-density lipoprotein cholesterol (HDL-C) in the SDH group, and a significant interaction was also found between TyG index and body mass index (BMI) in the ISH group.

Conclusion

Triglyceride-glucose index may potentially serve as a novel indicator for IDH and SDH. Our findings could also inform the development and implementation of targeted screening for hypertension.

Treatment With Lisinopril Prevents the Early Progression of Glomerular Injury in Obese Dahl Salt-Sensitive Rats Independent of Lowering Arterial Pressure

Recently, we reported that obese Dahl salt-sensitive leptin receptor mutant (SSLepRmutant) rats develop glomerular injury and progressive proteinuria prior to puberty. Moreover, this early progression of proteinuria was associated with elevations in GFR. Therefore, the current study examined whether treatment with lisinopril to reduce GFR slows the early progression of proteinuria in SSLepRmutant rats prior to puberty. Experiments were performed on 4-week-old SS and SSLepRmutant rats that were either treated with vehicle or lisinopril (20 mg/kg/day, drinking water) for 4 weeks. We did not observe any differences in MAP between SS and SSLepRmutant rats treated with vehicle (148 ± 5 vs. 163 ± 6 mmHg, respectively). Interestingly, chronic treatment with lisinopril markedly reduced MAP in SS rats (111 ± 3 mmHg) but had no effect on MAP in SSLepRmutant rats (155 ± 4 mmHg). Treatment with lisinopril significantly reduced proteinuria in SS and SSLepRmutant rats compared to their vehicle counterparts (19 ± 5 and 258 ± 34 vs. 71 ± 12 and 498 ± 66 mg/day, respectively). Additionally, nephrin excretion was significantly elevated in SSLepRmutant rats versus SS rats, and lisinopril reduced nephrin excretion in both strains. GFR was significantly elevated in SSLepRmutant rats compared to SS rats, and lisinopril treatment reduced GFR in SSLepRmutant rats by 30%. The kidneys from SSLepRmutant rats displayed glomerular injury with increased mesangial expansion and renal inflammation versus SS rats. Chronic treatment with lisinopril significantly decreased glomerular injury and renal inflammation in the SSLepRmutant rats. Overall, these data indicate that inhibiting renal hyperfiltration associated with obesity is beneficial in slowing the early development of glomerular injury and renal inflammation.

Obese Neotomodon alstoni mice exhibit sexual dimorphism in the daily profile of circulating melatonin and clock proteins PER1 and BMAL1 in the hypothalamus and peripheral oscillators

Obesity is a global health threat and a risk factor for several metabolic conditions. Though circadian dysfunction has been considered among the multiple causes of obesity, little work has been done to explore the relationship between obesity, circadian dysfunction, and sexual dimorphism. The Neotomodon alstoni mouse is a suitable model for such research. This study employed N. alstoni mice in a chronobiological analysis to determine whether there is circadian desynchronization of relative PER1 and BMAL1 protein levels in the hypothalamus, liver, visceral white adipose tissue, kidney, and heart. It also compared differences between sexes and lean and obese N. alstoni adult mice, by recording behavior and daily circulating serum melatonin as markers of circadian output. We found that obese mice display reduced locomotor activity. Additionally, Cosinor analyses of the relative expression of PER1 and BMAL1 show differences between lean and obese mice in a sex-linked manner. The PER1 24 h rhythm was absent in all tissues of obese males and significant in the tissues of obese females. The BMAL1 24 h rhythm also was significant in most of the tissues tested in lean males, whereas it was significant and shifted the acrophase (peak time of rhythm) in most of the tissues in obese females. Both lean male and female mice showed a rhythmic 24 h pattern of circulating serum melatonin. This daily profile was not only absent in obese mice of both sexes but showed sexual dimorphism. Obese male mice showed lower circulating levels of melatonin compared to lean male mice, but they were higher in obese females compared to lean females. Our results suggest that obesity in N. alstoni is associated with an internal circadian desynchronization in a sex-dependent manner. Overall, this study reinforces the need for further research on the neuroendocrinology of obesity and circadian rhythms using this biological model.

Insulin Resistance the Hinge Between Hypertension and Type 2 Diabetes

Epidemiological studies have documented a high incidence of diabetes in hypertensive patients.Insulin resistance is defined as a less than expected biologic response to a given concentration of the hormone and plays a pivotal role in the pathogenesis of diabetes. However, over the last decades, it became evident that insulin resistance is not merely a metabolic abnormality, but is a complex and multifaceted syndrome that can also affect blood pressure homeostasis. The dysregulation of neuro-humoral and neuro-immune systems is involved in the pathophysiology of both insulin resistance and hypertension. These mechanisms induce a chronic low grade of inflammation that interferes with insulin signalling transduction. Molecular abnormalities associated with insulin resistance include the defects of insulin receptor structure, number, binding affinity, and/or signalling capacity. For instance, hyperglycaemia impairs insulin signalling through the generation of reactive oxygen species, which abrogate insulin-induced tyrosine autophosphorylation of the insulin receptor. Additional mechanisms have been described as responsible for the inhibition of insulin signalling, including proteasome-mediated degradation of insulin receptor substrate 1/2, phosphatase-mediated dephosphorylation and kinase-mediated serine/threonine phosphorylation of both insulin receptor and insulin receptor substrates. Insulin resistance plays a key role also in the pathogenesis and progression of hypertension-induced target organ damage, like left ventricular hypertrophy, atherosclerosis and chronic kidney disease. Altogether these abnormalities significantly contribute to the increase the risk of developing type 2 diabetes.

Bariatric Surgery for Resistant Hypertension: Working in Progress!

PURPOSE OF REVIEW

To discuss the recent evidence pointing the benefits of the bariatric surgery on blood pressure control in patients with obesity and hypertension. Particular focus is devoted to discuss the potential impact on resistant hypertension.

RECENT FINDINGS

Growing evidence suggest that bariatric surgery promotes not only a significant reduction in the anti-hypertensive medication while maintained blood pressure control but also a significant proportion of hypertension remission as compared to the usual care. In a sub-analysis of the GATEWAY trial using both office and 24-h ambulatory blood pressure monitoring, the prevalence of resistant hypertension significantly decreased after 12 months in the surgical group whereas the numbers remained stable in the control group. Despite the lack of robust evidence, preliminary findings underscore the strong need to explore the potential role of bariatric surgery on resistant hypertension in patients with obesity. This statement is justified not only for the burden of obesity in this scenario but also for the unmet demands in managing resistant hypertension appropriately by multiple drug-therapy or the lack of real utility of procedures like renal denervation and carotid baroreflex activation.

The prevalence of metabolic syndrome and its association with body fat distribution in middle-aged individuals from Indonesia and the Netherlands: a cross-sectional analysis of two population-based studies

BACKGROUND

The prevalence of metabolic syndrome varies among populations with different ethnicities. Asian populations develop metabolic complications at lower amounts of adiposity than western populations. The role of abdominal obesity in the metabolic differences between the two populations is poorly understood.

OBJECTIVES

Our objectives were to estimate the prevalence of metabolic syndrome and the relative contribution of its components in the Indonesian and the Dutch population, as well as to examine the associations of overall and abdominal obesity with metabolic syndrome.

METHODS

In this cross-sectional study of middle-aged adults in the Netherlands Epidemiology of Obesity Study (n = 6602) and the Indonesian National Health Surveillance (n = 10,575), metabolic syndrome was defined by the unified IDF and AHA/NHLBI criteria. We performed logistic and linear regressions to examine associations of BMI and waist circumference with the metabolic syndrome, mutually adjusted for waist circumference and BMI.

RESULTS

The prevalence of metabolic syndrome was 28% and 46% in Indonesian men and women, and 36% and 24% in Dutch men and women. The most prominent components were hypertension (61%) and hyperglycemia (51%) in the Indonesian, and hypertension (62%) and abdominal obesity (40%) in the Dutch population. Per SD in BMI and waist circumference, odds ratios (ORs, 95% CI) of metabolic syndrome were 1.5 (1.3-1.8) and 2.3 (1.9-2.7) in Indonesian men and 1.7 (1.2-2.5) and 2.9 (2.1-4.1) in Dutch men. The ORs of metabolic syndrome were 1.4 (1.2-1.6) and 2.3 (2.0-2.7) in Indonesian women and 1.0 (0.8-1.3) and 4.2 (3.2-5.4) in Dutch women.

CONCLUSION

More Indonesian women than men have metabolic syndrome, whereas the opposite is true for the Dutch population. In both the Indonesian and the Dutch populations, hypertension is the primary contributor to the prevalence of metabolic syndrome. In both populations, abdominal adiposity was more strongly associated with metabolic syndrome than overall adiposity.

Comparison of Oral Antidiabetic Drugs as Add-On Treatments in Patients with Type 2 Diabetes Uncontrolled on Metformin: A Network Meta-Analysis

We assessed the efficacy and safety of oral antidiabetic drugs (OADs) as an add-on treatment in patients with type 2 diabetes uncontrolled on metformin. PubMed, the Cochrane Library, and Embase were searched from inception to October 20, 2017. Pairwise and network meta-analyses were conducted using Stata 14.1 software. Odds ratios (ORs) and weighted mean differences (WMDs) were used to evaluate outcomes. Sixty-eight trials including 36,746 patients were analyzed. No significant differences in the risk of major adverse cardiovascular events (MACEs) and all-cause mortality were observed among any class of OADs when combined with metformin. All classes of OADs as add-ons to metformin improved glucose control, while sodium-glucose co-transporter-2 (SGLT-2) inhibitors showed greater fasting plasma glucose (FPG) reductions {WMD, - 1.49 [95% confidence interval (CI) - 1.69 to - 1.28] mmol/l} and 2 h postprandial glucose (2 h PPG) reductions [WMD, - 3.07 (95% CI - 4.12 to - 2.03) mmol/l]. Thiazolidinediones and sulfonylureas were associated with weight gain [WMD, 2.53 (95% CI 1.95-3.10) kg and 2.00 (95% CI 1.63-2.36) kg, respectively] when added to metformin. Sulfonylureas [WMD, 6.52 (95% CI 4.07-10.45)] were associated with the highest ORs of hypoglycemia. Our results suggest that the seven classes of OADs were not associated with any increased risk of MACEs or all-cause mortality when combined with metformin. Most OADs were associated with similarly large reductions in HbA1c levels when added to metformin, while SGLT-2 inhibitors might be the best option for reducing body weight, FPG, and 2-h PPG.

Epidemiological investigation into the prevalence of abnormal inter-arm blood pressure differences among different ethnicities in Xinjiang, China

OBJECTIVES

The prevalence of and risk factors for IAD among different ethnicity groups was unknown. Our aim was to investigate the prevalence of and risk factors for IAD among Han, Uygur and Kazakh ethnicities in Xinjiang. China.

METHODS

In total, 14,618 adult participants (7,799 males and 6,819 females) were recruited from the Cardiovascular Risk Survey. A 4-stage stratified cluster random sampling method was used. The participants' personal information and medical history were assessed by questionnaire. IAD was diagnosed by a noninvasive arteriosclerosis analyzer.

RESULTS

The prevalence of abnormal IAD among the general population was 14.3%, with 12.5% in the Han, 14.9% in the Uygur, and 16.4% in the Kazakh populations. The prevalence of abnormal IAD among the hypertensive population was 19.4%, with 17.0% in the Han, 18.1% in the Uygur, and 22.7% in the Kazakh populations. The prevalence of abnormal IAD increased with age (all P < 0.01) but was not significantly different between the genders (all P> 0.05). Multivariate logistic regression analysis showed that age more than 45 years, obesity and hypertriglyceridemia were significantly associated with a higher prevalence of IAD. There were different risk factors for abnormal IAD in different ethnicities. Middle or old age, obesity, ABI and diabetes mellitus were risk factors for the Han population, smoking was a risk factor in the Uygur population, and obesity and PAD were risk factors in the Kazakh population.

CONCLUSION

The prevalence of abnormal IAD in the Kazakh participants was higher than that in the Han and Uygur populations among both the general population and the hypertensive population in Xinjiang, China. The main risk factors of IAD were age, obesity, and triglyceride levels. Different ethnicities had different kinds of risk factors for IAD.

The association between obesity, hypertension and left ventricular mass in adolescents

BACKGROUND

Obesity and hypertension (HT) are well known cardiac risk factors. Our goal was to show that even if arterial blood pressure (BP) measurements of obese adolescents are normal during clinical examination, ambulatory blood pressure monitoring (ABPM) can be high, may include cardiac involvement and can also detect left ventricular mass indices (LVMI) value for obese adolescents to diagnose left ventricular hypertrophy (LVH).

METHODS

This study included 130 children (57 obese hypertensive, 36 obese normotensive, 14 normal weight hypertensive and 23 normal weight normotensive). Adolescents whose BP was measured during clinical examination, after 24-h BP was detected using ABPM, were examined with echocardiography for calculation of LVMI to determine cardiac risk factors for LVH.

RESULTS

There was a significant difference between the LVMI of obese-normotensive and obese-hypertensive adolescents, which showed the effect of obesity on LVMI independent of HT. Twenty (35.7%) of 56 obese adolescents with HT detected with ABPM had normal BP measurements during clinical examination. Dipper and nondipper features of obese adolescents were significantly higher in ABPM than those with normal body mass index. When the cutoff LVMI value for LVH was set at ≥38 g/m2.7, 38.9% of obese-normotensive and 50.9% of obese-hypertensive subjects had LVH; however, when the cutoff value was set at ≥51 g/m2.7, the rates were 2.8% and 19.3%, respectively.

CONCLUSIONS

Obesity is a risk factor for LVH independent of HT. To identify masked HT, 24-h ABPM and cardiac examination should be routinely performed in obese adolescents. Using a limit of LVMI ≥38 g/m2.7 in evaluating LVH secondary to HT in obese individuals may lead to an overestimated diagnosis rate of LVH.

Molecular genetics of human obesity: A comprehensive review

Obesity and its related health complications is a major problem worldwide. Hypothalamus and their signalling molecules play a critical role in the intervening and coordination with energy balance and homeostasis. Genetic factors play a crucial role in determining an individual's predisposition to the weight gain and being obese. In the past few years, several genetic variants were identified as monogenic forms of human obesity having success over common polygenic forms. In the context of molecular genetics, genome-wide association studies (GWAS) approach and their findings signified a number of genetic variants predisposing to obesity. However, the last couple of years, it has also been noticed that alterations in the environmental and epigenetic factors are one of the key causes of obesity. Hence, this review might be helpful in the current scenario of molecular genetics of human obesity, obesity-related health complications (ORHC), and energy homeostasis. Future work based on the clinical discoveries may play a role in the molecular dissection of genetic approaches to find more obesity-susceptible gene loci.

The impacts of obesity on the cardiovascular and renal systems: cascade of events and therapeutic approaches

There is a neglected epidemic of both obesity and metabolic syndrome in industrialized and unindustrialized countries all over the globe. Both conditions are associated with a high incidence of other serious pathologies, such as cardiovascular and renal diseases. In this article, we review the potential underlying mechanisms by which obesity and metabolic syndrome promote hypertension, including changes in cardiovascular-renal physiology induced by leptin, the sympathetic nervous system, the renin-angiotensin-aldosterone system, insulin resistance, free fatty acids, natriuretic peptides, and proinflammatory cytokines. We also discuss the potential underlying mechanisms by which obesity promotes other cardiovascular and renal conditions, as well as available nonpharmacologic and pharmacologic approaches for treating obesity-induced hypertension. The findings presented herein suggest that adipocytes may be a key regulator of cardiovascular and renal function.

Prevalence of Isolated Diastolic Hypertension and Associated Risk Factors among Different Ethnicity Groups in Xinjiang, China

Objectives

Little is known about isolated diastolic hypertension (IDH) among different ethnicity groups. We aimed to investigate the prevalence and risk factors for IDH among the major ethnicity population i.e. Han, Uygur and Kazakh in Xinjiang, northwestern part of China.

Methods

In total, 14,618 adult participants (7,799 males, 6,819 females) were recruited from the Cardiovascular Risk Survey conducted during 2007 and 2010. Blood pressure, body mass index and standard lipid profile and fasting glucose level from plasma were measured.

Results

The overall prevalence of IDH was 10.8% in the Han, 4.5% in the Uygur and 8.7% in the Kazakh populations. When stratified by gender, IDH prevalence was 9.8% in men and 6.8% in women (P<0.001). The prevalence of IDH also varied significantly with age and it was highest in those aged 35–44 yrs old (9.7%) and lowest in those over 75 yrs old (4.1%, P<0.001). Multivariate logistic regression analysis showed that overweight (OR = 1.179, 95%CI: 1.015–1.369) or obesity (OR = 1.202, 95%CI: 1.015–1.424), smoking (OR = 1.362, 95%CI: 1.156–1.604) and high total cholesterol (TC) hyperlipidemia (OR = 1.237, 95%CI: 1.074–1.423) were significantly associated with a higher prevalence of IDH. Identified risk factors for IDH differed among ethnicity groups with male gender, young age (35–44 yrs old), more coffee or tea consumption and high TC hyperlipidemia in the Han; smoking and often coffee or tea consumption in the Uygur and male gender and overweight or obesity in the Kazakh populations.

Conclusions

IDH prevalence in the Han population is higher than that in the Uygur and Kazak populations in Xinjiang, northwestern part of China. Male gender, middle age, overweight or obesity, smoking and high TC hyperlipidemia appear to be relevant risk factors of IDH in adults. Different ethnicity background had different sets of risk factors for IDH.

Do Obese Individuals With Hypertension Have More Difficult-to-Control Blood Pressure and End Organ Damage Than Their Nonobese Counterparts?

The authors assessed whether individuals with elevated body mass index (BMI) and hypertension had more difficult-to-control blood pressure (BP) and more evidence of end organ damage using data collected prospectively over 11 years from a secondary care hypertension clinic. A total of 1114 individuals were divided by BMI criteria into normal (n=207), overweight (n=440), and obese (n=467). Mean daytime, nighttime, and 24-hour systolic BP and diastolic BP were similar in all groups. There was less nocturnal dip in obese compared with overweight groups (P=.025). Individuals with a normal BMI were taking fewer antihypertensive medications than those in the obese group (P=.01). Individuals classified as obese had a higher left ventricular mass index than those with a normal BMI (female, P=.028; male, P<.001); this relationship remained after multivariate linear regression. Obese individuals with hypertension required more medication to achieve similar mean ambulatory BP values, had less nocturnal dip in BP, and had a higher prevalence of left ventricular hypertrophy. As such, obese patients are at potentially increased risk of cardiovascular events.

The pathophysiology of hypertension in patients with obesity

The combination of obesity and hypertension is associated with high morbidity and mortality because it leads to cardiovascular and kidney disease. Potential mechanisms linking obesity to hypertension include dietary factors, metabolic, endothelial and vascular dysfunction, neuroendocrine imbalances, sodium retention, glomerular hyperfiltration, proteinuria, and maladaptive immune and inflammatory responses. Visceral adipose tissue also becomes resistant to insulin and leptin and is the site of altered secretion of molecules and hormones such as adiponectin, leptin, resistin, TNF and IL-6, which exacerbate obesity-associated cardiovascular disease. Accumulating evidence also suggests that the gut microbiome is important for modulating these mechanisms. Uric acid and altered incretin or dipeptidyl peptidase 4 activity further contribute to the development of hypertension in obesity. The pathophysiology of obesity-related hypertension is especially relevant to premenopausal women with obesity and type 2 diabetes mellitus who are at high risk of developing arterial stiffness and endothelial dysfunction. In this Review we discuss the relationship between obesity and hypertension with special emphasis on potential mechanisms and therapeutic targeting that might be used in a clinical setting.

Therapeutic interventions for hypertension in metabolic syndrome: a comprehensive approach

Hypertension is a major component of the metabolic syndrome and a major cardiovascular risk factor. Both disorders are rapidly increasing in frequency, with hypertension affecting nearly 60 million Americans and over 1 billion people worldwide, and metabolic syndrome affecting 44% of the US population above the age of 60 years. Sedentary lifestyle, together with obesity and aging of the population, are the major contributing factors for this growing epidemic. Hypertension in metabolic syndrome possesses unique pathophysiological aspects that have considerable implications on therapy of this disease. In this article, we review the pathophysiology and provide a rationale for the current therapeutic options in light of the most recent clinical trials in the field.

The heart in obesity-hypertension

There is growing recognition that obesity is reaching epidemic proportions throughout the world. In adults, obesity is associated with increased cardiovascular morbidity and mortality. A series of endocrine, metabolic and hemodynamic mechanisms have been responsible for the development of obesity-hypertension. These mechanisms include: a suppressed biologic activity and availability of natriuretic peptide, increased sympathetic adrenergic activity, release of angiotensin ll from adipocytes and activation of the renin-angiotensin-aldosterone system, leptin resistance, chronic hyperleptinemia and hyperinsulinemia. The systemic hemodynamic profile of obesity includes high intravascular volume, increased cardiac output and inappropriately normal peripheral resistance. The cardiovascular adaptations to these changes include changes in vascular responsiveness and concentric-eccentric left ventricular hypertrophy, and may be responsible for increased risk of congestive heart failure, arrhythmia and sudden death.

Thrombospondin 1 mediates renal dysfunction in a mouse model of high-fat diet-induced obesity

Obesity is prevalent worldwide and is a major risk factor for many diseases including renal complications. Thrombospondin 1 (TSP1), a multifunctional extracellular matrix protein, plays an important role in diabetic kidney diseases. However, whether TSP1 plays a role in obesity-related kidney disease is unknown. In the present studies, the role of TSP1 in obesity-induced renal dysfunction was determined by using a diet-induced obese mouse model. The results demonstrated that TSP1 was significantly upregulated in the kidney from obese mice. The increased TSP1 was localized in the glomerular mesangium as well as in the tubular system from obese wild-type mice. Obese wild-type mice developed renal hypertrophy and albuminuria, which was associated with increased kidney macrophage infiltration, augmented kidney inflammation, and activated transforming growth factor (TGF)-β signaling and renal fibrosis. In contrast, obese TSP1-deficient mice did not develop these kidney damages. Furthermore, in vitro studies demonstrated that leptin treatment stimulated the expression of TSP1, TGF-β1, fibronectin, and collagen type IV in mesangial cells isolated from wild-type mice. These leptin-stimulated effects were abolished in TSP1-deficient mesangial cells. Taken together, these data suggest that TSP1 is an important mediator for obesity- or hyperleptinemia-induced kidney dysfunction.

Non-invasive assessment of maternal hemodynamics in early pregnancy

OBJECTIVES

Non-invasive assessment of maternal hemodynamics in early pregnancy may be promising in evaluating maternal hemodynamic (mal)adaptation to pregnancy. We explored usage of applanation tonometry and Doppler ultrasound for assessment of cardiac output (CO), systemic vascular resistance (SVR) and arterial stiffness in early pregnancy.

METHODS

Pregnant healthy nulliparous women were studied during first trimester. Radial artery pressure waveform (augmentation index(AIx)), carotid-femoral pulse wave velocity (PWV) and cardiac output (CO) were measured by applanation tonometry (SphygmoCor), electrocardiogram and Doppler ultrasound (USCOM) and related to maternal demographic characteristics and literature concerning advanced pregnancy and non-pregnant subjects.

RESULTS

116 women were studied during gestational age range of 7(+2)-14weeks. Systolic and diastolic central blood pressure were correlated with systolic and diastolic brachial blood pressure respectively. Both measures of arterial stiffness (heart rate corrected AIx(AIx@75) and PWV) were correlated. AIx@75, PWV and SVR were correlated with central mean arterial pressure. CO was negatively correlated with AIx and associated with BMI. PWV was associated with age and BMI, whereas SVR was associated with age.

CONCLUSIONS

Applanation tonometry and Doppler Ultrasound for assessment of maternal hemodynamics in early pregnancy revealed similar associations between different hemodynamic parameters and maternal characteristics as have previously been reported in advanced pregnancy and non-pregnant subjects. The SphygmoCor and the USCOM appear to be reliable methods for the assessment of maternal hemodynamics in early pregnancy. Obtaining a comprehensive hemodynamic profile using these modalities may offer insight in maternal (mal)adaptation to pregnancy. Future work needs to be done relating such measures to pregnancy outcome.

Obesity Does Not Increase Morbidity and Mortality after Laparotomy for Trauma

Obesity has been suggested to be a risk factor for increase morbidity and mortality after trauma and surgery. Trauma laparotomy provides an opportunity to assess the effect of body mass index (BMI) on patients subjected to both trauma and surgery. We hypothesized that obesity would have a deleterious effect on outcomes. A retrospective review was conducted of all patients 18 years of age or older undergoing laparotomy for trauma between July 2001 and June 2011. Patients were stratified according to BMI into the following four groups: underweight (16 to 22 kg/m2), normal (23 to 27 kg/m2), overweight (28 to 34 kg/m2), and obese (35 kg/m2 or higher). Data on the patient's hospital course included length of stay, mortality, respiratory failure, infectious complications, wound dehiscence, and organ failure. A total of 1,297 patients underwent laparotomy. Seven per cent of the study group was obese and 24 per cent was underweight. There was no difference among mean Injury Severity Score, percent of patients arriving in shock, and mean number of units of packed red blood cells administered during their hospital stay. Obese patients had longer intensive care unit and hospital lengths of stay. There were no differences in ventilator days or mortality. Using univariate statistics, obese patients had increased rates of respiratory and renal failure, bacteremia with and without septic shock, and abdominal wound dehiscence. Subjecting the data to logistic regression analysis, BMI was no longer an independent predictor of any complication. Although obese trauma patients do have increased infectious morbidity, wound dehiscence, and a prolonged length of stay, increased BMI is not an independent predictor of increased morbidity or mortality after trauma laparotomy.

Exercise, insulin resistance, and hypertension: a complex relationship

More than 300,000 deaths occur annually in the United States alone as a result of obesity, poor dietary habits, or physical inactivity. Obesity is now an increasingly recognized independent risk factor for cardiovascular disease and leads to numerous other comorbidities. The causal relationships between obesity and both insulin resistance and hypertension have been consistently demonstrated in numerous studies. The relationships consist of cascading events involving insulin, leptin, adiponectin, and other hormones that often precipitate the development of metabolic syndrome. As we learn more about the metabolic activity of the adipose tissue, we can better identify the mechanisms that associate weight reduction with a decrease in health risks. Evidence suggests that exercise produces a positive effect on weight reduction, insulin sensitivity, and blood pressure. Therefore, weight reduction and therapeutic changes in lifestyle should be encouraged in all overweight and obese patients. It is imperative to increase the awareness of the obesity epidemic and to emphasize the importance of exercise as both treatment and prevention of metabolic disease.

Leptin and Nitric Oxide Production in Normotensive and Hypertensive Men

OBJECTIVE

Recent findings have shown that leptin, the product of the obesity gene, may actively participate in the regulation of blood pressure and other cardiovascular functions through the nitric oxide (NO)-dependent mechanism.

RESEARCH METHODS AND PROCEDURES

In this study, to test the hypothesis that leptin regulation of NO metabolism is impaired in hypertension, we examined the possible relationship between circulating leptin and plasma NO metabolite level in normotensive (NT) and hypertensive (HT) men.

RESULTS

There were significant correlations between circulating leptin and BMI in both the NT and HT groups (NT: r = 0.64, n = 26, p < 0.01; HT: r = 0.59, n = 22, p < 0.01). The concentration of circulating leptin was similar between the NT and HT men, although the plasma NO metabolite level (nitrite and nitrate) was significantly reduced in the HT men compared with the NT men (NT: 51.0 +/- 4.9 microM, n = 26; HT: 37.1 +/- 2.5 microM, n = 22, p < 0.05). The circulating leptin was significantly correlated with the plasma NO metabolite level in the overall analysis of the NT and HT men (r = 0.35, n = 48, p < 0.05). When the analysis of the correlation for the NT and HT men was performed separately, there was a significant correlation between circulating leptin and plasma NO metabolites in the NT men (r = 0.45, n = 26, p < 0.05) but not in the HT men (r = 0.15, n = 22). The results of this study are consistent with the hypothesis that leptin-related metabolism of NO might be altered in HT men.

Performance of Two Self-Report Measures for Evaluating Obesity and Weight Loss*

OBJECTIVES

To evaluate performance of the Obesity and Weight-Loss Quality-of-Life (OWLQOL) and Weight-Related Symptoms (WRSM) measures.

RESEARCH METHODS AND PROCEDURES

Four studies of obese persons 18 to 75 years of age were analyzed: a 12-week initial validation study, a clinical trial using blinded endpoint data at 50 to 83 weeks, and community studies conducted in the U.S. and Europe. Fifty-six initial validation study subjects visited 1 week after screening to evaluate reproducibility.

RESULTS

Overall, 6107 obese persons completed one assessment, 291 completed follow-up at 12 weeks, and 642 at >50 weeks. Psychometric analyses resulted in a 17-item OWLQOL with a single score tested on five samples that was internally consistent (alpha values > 0.90) and reproducible (intraclass correlation coefficient > 0.95). The OWLQOL score (higher is better) was associated, as expected, with the symptom measure (lower is better, -0.54), generic quality of life measure (0.53), and measures of physical (0.40) and mental functioning (0.47). The 20-item WRSM was internally consistent (alpha = 0.87) and reproducible (intraclass correlation coefficient = 0.83). The OWLQOL discriminated between genders (p < 0.001), presence of disability days (p < 0.05), levels of BMI (p < 0.05), and levels of symptom bothersomeness (p < 0.001). Evaluation at 12 weeks yielded an effect size for > or = 2.5% weight loss of 0.77 for the OWLQOL and -0.54 for the WRSM. At > or = 50 weeks for > or = 10% weight change, effect sizes were 1.63 and -0.73, respectively.

DISCUSSION

The OWLQOL and WRSM are brief, valid, reproducible, and responsive self-reported outcomes for evaluating obesity and weight loss.

Visceral adipose tissue: emerging role of gluco- and mineralocorticoid hormones in the setting of cardiometabolic alterations

Several clinical and experimental lines of evidence have highlighted the detrimental effects of visceral adipose tissue excess on cardiometabolic parameters. Besides, recent findings have shown the effects of gluco-and mineralocorticoid hormones on adipose tissue and have also underscored the interplay existing between such adrenal steroids and their respective receptors in the modulation of adipose tissue biology. While the fundamental role played by glucocorticoids on adipocyte differentiation and storage was already well known, the relevance of the mineralocorticoids in the physiology of the adipose organ is of recent acquisition. The local and systemic renin–angiotensin–aldosterone system (RAAS) acting on adipose tissue seems to contribute to the development of the cardiometabolic phenotype so that its modulation can have deep impact on human health. A better understanding of the pathophysiology of the adipose organ is of crucial importance in order to identify possible therapeutic approaches that can avoid the development of such cardiovascular and metabolic sequelae.

The impact of sleeve gastrectomy on hypertension: a systematic review

Laparoscopic sleeve gastrectomy (LSG) is a relatively new bariatric surgical procedure associated with an acceptable weight loss and a relatively low morbidity. There is existing evidence suggesting bariatric surgery resolves or improves hypertension. The purpose of this study is to systematically review the effect of LSG on hypertension. An electronic search method was primarily used for identification of the studies. We performed a comprehensive search of all electronic databases (MEDLINE, PubMed, Embase, Scopus, Dare, Clinical Evidence, BIOSIS, Previews, TRIP, Web of Science, Health Technology Database, Conference abstracts, clinical trials, and the Cochrane Library database) using broad search terms. All human studies from August 2000 to September 2011 were included. After an initial screening, a total of 326 studies were identified. After assessment of these studies based on our exclusion criteria, 222 studies were considered for the abstract review. A total of 33 studies were identified after a careful screening, involving a total of 3,997 patients. The mean pre-operative body mass index (BMI) was 49.1 ± 7.5 kg/m(2) (range 37-68). The average follow-up time was 16.9 ± 9.8 months (range 12-48). The mean post-operative BMI was 36 ± 7.0 kg/m(2) (range 25.6-54). LSG resulted in resolution of hypertension in 58% of patients. On average, 75% of patients experienced resolution or improvement of their hypertension. Based on our systematic review, LSG has a significant effect on hypertension, inducing resolution or improvement in the majority of cases. Therefore, LSG remains a viable surgical option in obese patients with hypertension.

A predictive model for risk of prehypertension and hypertension and expected benefit after population-based life-style modification (KCIS No. 24)

BACKGROUND

Few reports have identified and quantified significant risk factors responsible for multistate natural course of progression to hypertension and also regression of prehypertension to normal, which provides baseline risks to estimate the size of expected benefit derived from population-based life-style modification.

METHODS

Data used for estimating clinical parameters governing temporal natural course of hypertension are derived from 42,027 participants attending screening annually between 1999 and 2002. Information on transition history between normal, prehypertension, stage 1 and stage 2 hypertension between screens was therefore collected to compute multistep composite risk scores without intervention program. The expected benefits of risk reduction in prehypertension and hypertension under different intervention programs by modifying the related risk factors from abnormal to normal ranges were estimated.

RESULTS

The majority of risk factors play a more remarkable role in prehypertension and stage 1 hypertension but less in stage 2 hypertension. The greater the number of risk factors included in the intervention programs becomes, the lower the mean risk score is expected to achieve. The 5-year predicted cumulative risk for stage 2 hypertension decreased from 23.6% in the absence of intervention program to 14% with the provision of "six-component intervention" in men. The results were similar for women.

CONCLUSIONS

Multiple risk factors responsible for multistep transitions between prehypertension and hypertension were identified by using population-based screening data to derive multistep composite risk scores, which are useful for the expected benefit of reducing risk of hypertension by providing population-based life-style modification.

Healthy weight - healthy blood pressure

World Hypertension Day is an initiative of the World Hypertension League. This year's theme is "Healthy weight - healthy blood pressure". According to the World Health Organization, more than one billion people worldwide are reported to be overweight and more than 300 million people are obese. Obesity is linked to hypertension, kidney diseases and other cardiovascular diseases. Through World Hypertension Day, the World Hypertension League, in partnership with national and international organizations, aims to raise the awareness of obesity and hypertension. Simple manoeuvres such as eating healthy, being physically active, and changing nutritional and dietary behaviours are recommended.

Diabetes and obesity: therapeutic targeting and risk reduction - a complex interplay

Obesity is a major risk factor for the development of diabetes and predisposes individuals to hypertension and dyslipidaemia. Together these pathologies increase the risk for cardiovascular disease (CVD), the major cause of morbidity and mortality in type 2 diabetes mellitus (T2DM). Worsening trends in obesity and T2DM raise a serious conundrum, namely, how to control blood glucose, blood pressure, and lipids when many antidiabetic agents cause weight gain and thereby exacerbate other cardiovascular risk factors associated with T2DM. Further, evidence suggests that some established antihypertensive agents may worsen glucose intolerance. Many patients who are obese, hypertensive, and/or hyperlipidaemic fail to achieve blood pressure, lipid and glycaemic goals, and this failure may in part be explained by physician reluctance to utilize complex combination regimens for fear of off-target effects. Thus, a clear need exists for clinicians to understand the risks and benefits of different pharmacologic, and indeed non-pharmacologic, options in order to maximize treatment outcomes. While intensive lifestyle modification remains an elusive gold standard, newer diabetes targets, including the incretin axis, may offer greater cardiovascular risk reduction than other antidiabetes therapies, although definitive clinical trial data are needed. The glucagon-like peptide-1 (GLP-1) receptor agonists exenatide and liraglutide and the dipeptidyl peptidase-4 (DPP-4) inhibitors sitagliptin and vildagliptin effectively lower HbA1c; exenatide and liraglutide reduce weight and blood pressure and improve lipid profiles. Sitagliptin and vildagliptin are weight neutral but also appear to improve lipid profiles. Integration of incretin therapies into the therapeutic armamentarium is a promising approach to improving outcomes in T2DM, and perhaps even in reducing complications of T2DM, such as co-morbid hypertension and dyslipidaemia. Additional long-term studies, including CVD end-point studies, will be necessary to determine the appropriate places for incretin-based therapies in treatment algorithms.

Prevalence and determinants of isolated systolic hypertension among young adults: the 1999-2004 US National Health And Nutrition Examination Survey

BACKGROUND

Little is known about isolated systolic hypertension (ISH) in younger adults. We examined the prevalence and determinants of ISH in this age group using the 1999-2004 National Health and Nutrition Examination Surveys (NHANES) and made comparisons using data from NHANES III (1988-1994).

METHODS

A total of 5685 adults aged 18-39 years and not on antihypertensive medications were analyzed. Prevalence estimates of ISH and potential risk factors were estimated by age and sex. For comparison of prevalence estimates with published reports of NHANES III data, age cutoffs (18-24, 25-34, and 35-44 year) by sex were also employed. A multivariate logistic regression model tested independent determinants of ISH.

RESULTS

ISH in young adults had a higher prevalence than systolic/diastolic hypertension (1.57 +/- 0.23% vs. 0.93 +/- 0.18%). ISH prevalence increased within the last decade particularly for men for each respective age category [men (0.8 vs. 2.2%, 1.3 vs. 2.4%, 1.3 vs. 2.4%), women (0.0 vs. 0.3%, 0.1 vs. 0.7%, 1.7 vs. 1.8%)]. On multivariate analysis, obesity [odds ratio (OR): 2.68, 95% confidence interval (CI): 1.06, 6.77], male sex (OR: 2.19, 95% CI: 1.10, 4.37), education level less than high school (OR: 2.98, 95% CI: 1.10, 8.06), and current smoking (OR: 2.06, 95% CI: 1.03, 4.11) were characteristics independently associated with higher odds of ISH among young adults. Relative increases in prevalence between the surveys were noted for current smoking (24.3 vs. 51.5%), obesity (33.9 vs. 42.7%) and low educational level (18.4 vs. 38.6%).

CONCLUSION

ISH among young adults is increasing in prevalence, and is more common than systolic/diastolic hypertension. Obesity, smoking, and low socioeconomic status appear to be important determinants of ISH among young adults and have all increased over the last decade.

Obesity and hypertension: mechanisms, cardio-renal consequences, and therapeutic approaches

The increasing prevalence of obesity in the industrialized world is causing an alarming epidemic. Almost 70% of American adults are overweight or obese. The link between increasing body weight and hypertension is well established. Obesity hypertension through metabolic, endocrinic, and systemic hemodynamic alteration causes structural vascular and cardiac adaptations that trigger concentric, eccentric left ventricular hypertrophy and electrophysiological changes, which may increase the risk for congestive heart failure and sudden cardiac death as a result of arrhythmias. The increased renal blood flow in conjunction with a decreased renal vascular resistance causes renal hyperperfusion and hyperfiltration. Such changes lead to glomerulomegaly, focal segmental glomerulosclerosis, tubulointerstitial inflammation, and fibrosis that characterize the renal damage in obese hypertensive subjects. We propose that weight reduction, with the addition of other nonpharmacological approaches that included exercise and reduction in alcohol intake, should be the first choice to treat obesity hypertension. Salt restriction may be helpful only in salt-sensitive patients. The benefits of diet in obese patients include improvement of insulin sensitivity, reduction in sympathetic nervous and renin angiotensin system activities, and restoration of leptin sensitivity. As a consequence of these and other metabolic changes, the previously described systemic and renal hemodynamic alterations improved and the cardiovascular and renal morphological changes induced by obesity were lessened. After reviewing the medications available, we believe that owing to the cardiovascular and renal morbidity and mortality that characterized obesity hypertension, the ACEI or ARBs offer the best cardio-renal protection and should be the pharmacologic treatment of choice. If these alone do not control BP adequately, then a low-dose diuretic should be added as a second approach. Although we strongly believe in our proposal, more multicenter long-term clinical pharmacological trials are needed to evaluate the efficacy and safety of the antihypertensive approaches in the treatment of obesity hypertension.

Strong association of physical job demands with functional limitations among active people: a population-based study in North-eastern France

PURPOSE

To assess the association between physical job demands (PJD) and physical/cognitive functional limitations, and the role of adverse health behaviours, obesity, and socio-demographic factors as confounders of those associations.

METHODS

The sample included 3,368 active subjects aged 18-64 years, randomly selected from North-eastern France. Subjects completed a post-mailed questionnaire. PJD score was defined as the product of years of employment with the cumulative number of a wide range of high job demands. Data were analysed through the logistic regression models.

RESULTS

The physical and cognitive functional limitations affected 16.9 and 28.6% of subjects, respectively. A strong relationship was found between PJD and physical functional limitation: significant odds ratios (OR) adjusted for all the factors studied 1.41 for PJD1-29, 1.72 for PJD30-99, and 2.57 for PJD >or=100 versus PJD0; and between PJD and cognitive functional limitation: OR 1.28 for PJD1-29, 1.60 for PJD30-99, and 2.00 for PJD >or=100 versus PJD0. Adverse health behaviours, obesity and job category were modest confounders of those associations.

CONCLUSIONS

This study identified a wide range of job demands and individual characteristics related to physical/cognitive functional limitations. Prevention should aim at improving working conditions and adverse health behaviours.

Analysis of retinal arteriolar structure in never-treated patients with essential hypertension

OBJECTIVE

Increased wall-to-lumen ratio of small arteries is a predictor of adverse cardiovascular prognosis. We aimed to analyze retinal arteriolar structure in never-treated patients with essential hypertension and to test whether elevated blood pressure is associated with an increased wall-to-lumen ratio of retinal arterioles.

METHODS

The study cohort comprised 21 untreated male patients with essential hypertension (mean age 39.1 +/- 5.4 years) and 29 untreated normotensive men (mean age 36.7 +/- 5.9 years). Wall-to-lumen ratio of retinal arterioles was assessed in vivo using scanning laser Doppler flowmetry.

RESULTS

Patients with essential hypertension had a higher wall-to-lumen ratio of retinal arterioles than normotensive individuals (0.36 +/- 0.1 vs. 0.28 +/- 0.1, P = 0.028). Wall cross-sectional area of retinal arterioles did not differ between the study groups. The growth index, indicating the percentage of difference in average wall cross-sectional area of retinal arterioles between both groups, was 18%. Both systolic (r = 0.360, P = 0.010) and diastolic (r = 0.536, P < 0.001) blood pressures were related to wall-to-lumen ratio of retinal arterioles. Multiple regression analysis including a variety of known cardiovascular risk factors revealed that blood pressure is independently associated with an increased wall-to-lumen ratio of retinal arterioles (systolic blood pressure: beta = 0.417, P = 0.012; diastolic blood pressure: beta = 0.548, P = 0.001).

CONCLUSION

The changes in arteriolar structure of retinal vessels in our study cohort revealed a similar pattern to that observed previously by other investigators in subcutaneous small arteries in essential hypertension. Blood pressure emerged as an important and independent determinant of wall-to-lumen ratio of retinal arterioles.

Pathogenic potential of adipose tissue and metabolic consequences of adipocyte hypertrophy and increased visceral adiposity

When caloric intake exceeds caloric expenditure, the positive caloric balance and storage of energy in adipose tissue often causes adipocyte hypertrophy and visceral adipose tissue accumulation. These pathogenic anatomic abnormalities may incite metabolic and immune responses that promote Type 2 diabetes mellitus, hypertension and dyslipidemia. These are the most common metabolic diseases managed by clinicians and are all major cardiovascular disease risk factors. 'Disease' is traditionally characterized as anatomic and physiologic abnormalities of an organ or organ system that contributes to adverse health consequences. Using this definition, pathogenic adipose tissue is no less a disease than diseases of other body organs. This review describes the consequences of pathogenic fat cell hypertrophy and visceral adiposity, emphasizing the mechanistic contributions of genetic and environmental predispositions, adipogenesis, fat storage, free fatty acid metabolism, adipocyte factors and inflammation. Appreciating the full pathogenic potential of adipose tissue requires an integrated perspective, recognizing the importance of 'cross-talk' and interactions between adipose tissue and other body systems. Thus, the adverse metabolic consequences that accompany fat cell hypertrophy and visceral adiposity are best viewed as a pathologic partnership between the pathogenic potential adipose tissue and the inherited or acquired limitations and/or impairments of other body organs. A better understanding of the physiological and pathological interplay of pathogenic adipose tissue with other organs and organ systems may assist in developing better strategies in treating metabolic disease and reducing cardiovascular disease risk.

Maternal cardiac output between 11 and 13 weeks of gestation in the prediction of preeclampsia and small for gestational age

OBJECTIVE

To investigate maternal cardiac output in the first trimester as a predictor of preeclampsia and delivery of small for gestational age (SGA) infants.

METHODS

In women attending for routine care between 11(+0) and 13(+6) weeks of gestation, we recorded maternal variables and measured cardiac output by echocardiography. We compared cardiac output in those that developed preeclampsia (n=83), pregnancy-induced hypertension (PIH) (n=87), or SGA (n=532) with those unaffected by preeclampsia, PIH, or SGA (n=3,591). Regression analysis was used to first determine which of the factors among the maternal variables were significant predictors of cardiac output in the unaffected group and, secondly, to predict each complication by a combination of maternal variables and cardiac output.

RESULTS

In the unaffected group, cardiac output increased with gestation and maternal weight and decreased with maternal age. Cardiac output was higher in parous women, in cigarette smokers, in those taking antihypertensive or beta-mimetic medications, and in those conceiving after in vitro fertilization, and lower in women of Afro-Caribbean origin. Compared with the unaffected group, cardiac output was significantly higher in the preeclampsia and PIH groups and lower in the SGA group. In screening by cardiac output and maternal variables, for a 10% false-positive rate, the detection rates were 43.4% for all preeclampsia, 52% for preeclampsia without SGA, 23.3% for PIH, and 23.9% for SGA.

CONCLUSION

In pregnancies complicated by preeclampsia, PIH, and SGA, alterations in maternal cardiac output predate the clinical onset of the disorders by several months. Maternal cardiac output in the first trimester is increased in women who develop preeclampsia and decreased in women who deliver SGA infants.

LEVEL OF EVIDENCE

II.

Association of physical job demands, smoking and alcohol abuse with subsequent premature mortality: a 9-year follow-up population-based study

This study assessed the relationships of physical job demands (PJD), smoking, and alcohol abuse, with premature mortality before age 70 (PM-70) among the working or inactive population. The sample included 4,268 subjects aged 15 or more randomly selected in north-eastern France. They completed a mailed questionnaire (birth date, sex, weight, height, job, PJD, smoking habit, alcohol abuse (Deta questionnaire)) in 1996 and were followed for mortality until 2004 (9 yr). PJD score was defined by the cumulative number of the following high job demands at work: hammer, vibrating platform, pneumatic tools, other vibrating hand tools, screwdriver, handling objects, awkward posture, tasks at heights, machine tools, pace, working on a production line, standing about and walking. The data were analyzed using the Poisson regression model. Those with PM-70 were 126 (3.81 per 1,000 person-years). The leading causes of death were cancers (46.4% in men, 57.1% in women), cardiovascular diseases (20.2% and 11.9%), suicide (9.5% and 7.1%), respiratory diseases (6.0% and 4.8%), and digestive diseases (2.4% and 4.8%). PJD3, smoker, and alcohol abuse had adjusted risk ratios of 1.71 (95% CI 1.02-2.88), 1.76 (1.08-2.88), and 2.07 (1.31-3.26) respectively for all-cause mortality. Manual workers had a risk ratio of 1.84 (1.00-3.37) compared to the higher socio-economic classes. The men had a two-fold higher mortality rate than the women; this difference became non-significant when controlling for job, PJD, smoker and alcohol abuse. For cancer mortality the factors PJD3, smoker, and alcohol abuse had adjusted risk ratios of 2.00 (1.00-3.99), 2.34 (1.19-4.63), and 2.22 (1.17-4.20), respectively. Health promotion efforts should be directed at structural measures of task redesign and they should also concern lifestyle.

A life course of adiposity and dementia

Adiposity, commonly measured as body mass index (BMI), may influence or be influenced by brain structures and functions involved in dementia processes. Adipose tissue changes in degree and intensity over the lifespan, and has been shown to influence brain development in relationship to early and late measures of cognitive function, intelligence, and disorders of cognition such as dementia. A lower BMI is associated with prevalent dementia, potentially due to underlying brain pathologies and correspondingly greater rates of BMI or weight decline observed during the years immediately preceding clinical dementia onset. However, high BMI during mid-life or at least approximately 5-10 years preceding clinical dementia onset may increase risk. The interplay of adiposity and the brain occurring over the course of the lifespan will be discussed in relationship to developmental origins, mid-life sequelae, disruptions in brain structure and function, and late-life changes in cognition and dementia. Characterizing the life course of adiposity among those who do and do not become demented enhances understanding of biological underpinnings relevant for understanding the etiologies of both dementia and obesity and their co-existence.

The role of renin-angiotensin system blockade in the management of hypertension associated with the cardiometabolic syndrome

The mounting epidemic of overweight and obesity has made understanding the relationship between excess weight and associated comorbidities more urgent. Obesity is one of the strongest predictors of the development of hypertension and is an independent risk factor for cardiovascular disease, renal disease, and diabetes mellitus. The concomitant presence of obesity and hypertension, as commonly occurs in the cardiometabolic syndrome, magnifies the risk for cardiovascular and renal disease. The term "obesity-hypertension" thus serves to underscore the link between these two deleterious conditions and to emphasize the imperative for clinical intervention. Adipose tissue is now known to produce hormones and cytokines that promote inflammation, lipid accumulation, and insulin resistance. In addition, adipose tissue contains all the components of the renin-angiotensin system (RAS), which is upregulated in the presence of obesity. Evidence implicates activation of the systemic and adipose tissue RAS, as well as the sympathetic nervous system, as key obesity-related mechanisms of hypertension and other components of the cardiometabolic syndrome. RAS blockade therefore becomes a potential therapeutic strategy in patients with obesity-related hypertension and in persons with the cardiometabolic syndrome. Clinical trials of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers conducted in predominantly overweight/obese populations have demonstrated significant reductions in cardiovascular and renal disease risk among a range of at-risk patients. RAS blockade also is associated with a reduced risk of new-onset diabetes compared with other classes of antihypertensive therapy. Randomized, controlled trials conducted specifically in patients with obesity and hypertension are needed to determine the optimal therapeutic approach for these patients.

Hypertension in people with diabetes and the metabolic syndrome: pathophysiologic insights and therapeutic update

Hypertension (HTN) and type 2 diabetes mellitus (T2DM) are emerging as epidemics of the 21st century and are important components of the metabolic syndrome (MS). Evidence demonstrates a relationship between HTN, T2DM, and several vascular and metabolic abnormalities that are components of the MS. HTN affects nearly 70 million Americans and over one billion worldwide; likewise, the MS affects 44% of the US population above the age of 60 years and is rapidly increasing. HTN associated with the MS has certain pathophysiologic characteristics that provide clinical challenges. There is growing evidence that tissue activation of the renin-angiotensin system contributes to endothelial dysfunction, microalbuminuria, insulin resistance, and subsequent increased risk for cardiovascular and chronic kidney disease. The notion that HTN is a metabolic as well as a vascular disease provides a new treatment paradigm.

Leptin and hypertension in obesity

Leptin, a peptide discovered more than 10 years ago, decreases food intake and increases sympathetic nerve activity to both thermogenic and non-thermogenic tissue. Leptin was initially believed to be an anti-obesity hormone, owing to its metabolic effects. However, obese individuals, for unknown reasons, become resistant to the satiety and weight-reducing effect of the hormone, but preserve leptin-mediated sympathetic activation to non-thermogenic tissue such as kidney, heart, and adrenal glands. Leptin has been shown to influence nitric oxide production and natriuresis, and along with chronic sympathetic activation, especially to the kidney, it may lead to sodium retention, systemic vasoconstriction, and blood pressure elevation. Consequently, leptin is currently considered to play an important role in the development of hypertension in obesity.

Renal functional reserve in obesity hypertension

The capacity to increase glomerular filtration rate in response to an acute oral protein load is known as the renal functional reserve; the loss of such capacity is used as a marker of hyperfiltration. This physiological response in obese hypertensives is not yet fully understood. We aimed to study the interdependent effects of obesity and hypertension on renal reserve, taking into account renal kallikrein and nitric oxide in the modulation of that parameter. Fourteen obese hypertensives (mean age, 50.5 +/- 0.9 years) and nine lean hypertensives (mean age, 50.6 +/- 2.7 years) were evaluated. Renal haemodynamics and the levels of serum nitric oxide and urinary kallikrein were assessed at baseline and after a protein load (1 g/kg of body weight). An increase in the following parameters was observed when comparing obese and lean hypertensives: basal glomerular filtration rate; renal plasma flow; and urinary kallikrein and nitric oxide levels (129.2 +/- 2.9 vs. 101.4 +/- 3.4 ml/min/1.73 m2; 587.5 +/- 18.2 vs. 502.8 +/- 16.7 ml/min/1.73 m2; 0.120 +/- 0.02 vs. 0.113 +/- 0.02 mU/ml; 23.2 +/- 0.8 vs. 19.5 +/- 1.2 mmol/ml, respectively). The renal reserve was lower in obese hypertensives when compared with that of lean hypertensives (4.1 +/- 0.5 vs. 11.8 +/- 0.8 ml/min, p < 0.005). After a protein load, contrasting with the lean group, inability to elevate the nitric oxide serum levels and a lower increase in urinary kallikrein were observed in the obese group. These data suggest that obese hypertensives lose renal reserve earlier in the evolution to renal dysfunction. This may be due to the defective modulation of renal vasodilatation mechanisms by renal kallikrein and nitric oxide production.

Combating the epidemic of obesity and cardiovascular disease: perspectives from school-aged children

This study was designed to assess students' perceptions of the obstacles to positive dietary practices and increased physical activity and to solicit the students' recommendations for addressing and possibly reducing the negative practices that are associated with the rise in obesity and the development of cardiovascular diseases. Data for the study were obtained from the administration of the 2005 Project Health High School Survey (PHHSS) which measured the students' perceptions regarding obstacles to eating more nutritious, healthier foods and obstacles to participating in daily physical activity. The reasons for students' lack of interest in practicing more life-healthy behaviors are ranked and recorded. Some of the students indicated that they usually ate what they liked to eat, and the decision about what to eat was made because of the taste of the food without regard for any health consequence or negative health outcomes. Finding ways to reach these students at their young ages is the key to successfully combating the high prevalence of obesity and the development of other chronic diseases in childhood, as well as in adulthood.

Adiposity indices and dementia

Indicators of adiposity, such as body-mass index (BMI), may be markers for changes in energy metabolism that influence dementia risk, progression, and ultimately death. Cross-sectional studies show that people with dementia have a lower BMI than those without dementia, which is potentially due to a greater rate of BMI decline occurring during the years immediately preceding dementia onset. However, a high BMI can also increase the risk for dementia when measured before clinical dementia onset, which might be due to vascular disorders or bioactive hormonal compounds that are secreted by adipose tissue. In this personal view, I consider how dementia is associated with BMI by looking at the role of BMI and obesity syndromes, mechanisms associated with adiposity, and the potential for hypothalamic dysregulation during the life course. Understanding the life course of adiposity by use of common surrogate measures, such as BMI, among those who do and do not develop dementia is relevant for understanding the causes of dementia and for shaping possible treatment options.

Changes in Metabolic Syndrome Variables Since Childhood in Prehypertensive and Hypertensive Subjects

That essential hypertension is associated with metabolic syndrome is known. However, information is scant regarding the course of development of adverse levels of blood pressure and other risk variables of metabolic syndrome in youth at risk for developing hypertension. This aspect was studied, retrospectively, in a community-based cohort of normotensive (n=2206), prehypertensive (n=721), and hypertensive (n=328) subjects examined serially during childhood (4 to 11 years), adolescence (12 to 18 years), and adulthood (19 to 42 years). Prehypertensive subjects versus normotensive subjects had significantly higher body mass index and subscapular skinfold, systolic (SBP) and diastolic (DBP) blood pressures, and triglycerides beginning in childhood; higher glucose in adolescence; and higher low-density lipoprotein cholesterol, fasting insulin, and insulin resistance index in adulthood. Hypertensive subjects versus normotensive subjects had higher adiposity measures, SBP and DBP, glucose, and triglycerides beginning in childhood; higher insulin and insulin resistant index in childhood and adulthood; and lower high-density lipoprotein, cholesterol in adulthood. Most of these variables progressed adversely at an increased rate in prehypertensive and hypertensive subjects. In a multivariate analysis, adverse changes in adiposity, SBP, and DBP were independently associated with prehypertensive status; and adverse changes in adiposity, SBP and DBP, insulin resistant index, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides with hypertension status. As young adults, prehypertensive and hypertensive subjects showed significantly higher prevalence of obesity, hyperinsulinemia, hyperglycemia, and dyslipidemias. Thus, excess adiposity and blood pressure beginning in childhood and accelerated adverse longitudinal changes in risk variables of metabolic syndrome through young adulthood characterize the early natural history of hypertension.