Treating obesity can prevent, delay consequences of hypertension
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Key takeaways:
- Data show a potent class of obesity drugs and bariatric surgery each reduce blood pressure along with body weight.
- An “obesity first” strategy may reduce or eliminate the need for antihypertensive medicines.
Editor's Note: This is part 1 of a three-part Healio Exclusive series on the effect of obesity treatments on blood pressure. Part 2 can be viewed here. Part 3 can be viewed here.
The disease of obesity often brings cardiometabolic consequences, including hypertension, which remains the most potent and predictive risk factor for cardiovascular disease.
As the burden of obesity rises globally, so too does the prevalence of obesity-associated hypertension. Data from the U.S. National Health and Nutrition Examination Survey show that among the estimated 35.6% of adults with obesity, 24.7% had controlled hypertension and another 22.2% had uncontrolled hypertension, despite wide availability of inexpensive and safe antihypertensive therapies. Those with obesity and controlled or uncontrolled hypertension both had markedly higher risk for all-cause mortality compared with those who were normotensive.
“Obesity is a risk factor for all disease related to the blood vessels,” Sangeeta Kashyap, MD, assistant chief of clinical affairs in the division of endocrinology, diabetes and metabolism at NewYork-Presbyterian/Weill Cornell Medical Center, told Healio. “Treating obesity not only will prevent but will also delay complications related to hypertension. That includes kidney disease, heart disease and stroke — all the major killers in our patients.”
The newest class of obesity drugs, including the GLP-1 receptor agonist semaglutide 2.4 mg (Wegovy, Novo Nordisk) and the dual GLP-1/GIP agonist tirzepatide (Zepbound, Eli Lilly), have made headlines for inducing weight loss that approaches what is seen with bariatric surgery, which has been long considered the gold standard treatment for severe obesity. Now, data demonstrate that with substantial weight loss comes a sustained reduction in blood pressure and, for some, hypertension remission.
The emerging evidence suggests that obesity treatments, whether drugs or surgery, could potentially serve as a potent tool for the growing global burden of hypertension.
“Given that estimates of up to 75% of hypertension can be attributed to overweight or obesity, the impact of excess weight on BP is becoming a bigger problem,” Michael E. Hall, MD, MSc, professor and chair of the department of medicine and director of clinical and population sciences at the Mississippi Center for Clinical and Translational Research at University of Mississippi Medical Center in Jackson, told Healio. “By treating obesity, you are treating the root cause. With hypertension, we have good, effective therapies that are inexpensive and accessible, but even so, a large proportion of people with hypertension are suboptimally treated. But if you treat the obesity — the primary cause of the hypertension — you are going to the source and treating the source. Then you not only eliminate the need for the antihypertensive medications, but also the need for lipid and diabetes medications.”
Link between obesity, hypertension and CVD
The mechanisms through which obesity causes hypertension are complex and include sympathetic nervous system overactivation, stimulation of the renin-angiotensin-aldosterone system, alterations in adipose-derived cytokines, insulin resistance, and structural and functional renal changes, researchers wrote in a review published in Gland Surgery. Weight loss is the primary goal of treatment for obesity-related hypertension; however, few people are successful with lifestyle interventions alone.
“The easy way to think about this is, as your body mass increases, the arteries have to provide blood,” George L. Bakris, MD, formerly professor of medicine and director of the American Heart Association-accredited Comprehensive Hypertension Center at the University of Chicago Medicine, told Healio during an interview in April. (Editor’s note: Hypertension expert and longtime editorial board member for Healio George L. Bakris, MD, died June 15, 2024. Read Healio’s tribute to Dr. Bakris here.) “There is expansion, and within certain limits, this is OK. However, once you get to certain level — that is a BMI of around 30 kg/m2 — then you have gone beyond the means that a typical body can handle. The older you are, the more likely it is that the body is going to generate higher pressures to be able to deal with that.”
Adding to hypertension risk, Bakris said, are the drawbacks of a typical Western diet, such as sodium-rich foods, and consumption of alcohol in excessive amounts.
“All of that contributes in different ways, not just via calories in, but by activating specific systems to raised blood pressures,” Bakris said. “Notably, the sympathetic nervous system.”
Most of the trials assessing weight loss induced by lifestyle intervention show that, per 1 kg of weight loss, a person can expect about 1 mm Hg of BP lowering, according to Luke J. Laffin, MD, co-director of the Center for Blood Pressure Disorders at Cleveland Clinic.
“We know that obesity-associated hypertension is real,” Laffin told Healio. “It does not mean that everyone who is lean is going to have a normal BP or that everyone with obesity is going to have high BP. It really is a spectrum. However, individuals with obesity are much more likely to have diabetes, CVD and high BP.”.
Laffin said data show weight loss from bariatric surgery and some newer obesity medicines can “drastically” reduce BP.
“For some of these lower-risk patients with a BMI of, say, 35 kg/m2, with slightly elevated BP, LDL cholesterol and glucose — what if we treat the obesity right off the bat instead of prescribing three different medicines we know people do not want to take?” Laffin said. “Upfront treatment of obesity could prevent downstream complications and needing two or three medicines.”
Editor’s Note: Part 2 of this Healio Exclusive series will discuss the marked reductions in blood pressure observed among people with obesity treated with either medical therapy or bariatric surgery.
We want to hear from you:
Healio wants to hear from you: Could “obesity-first” management serve as a solution to treating multiple cardiometabolic conditions, such as hypertension? Share your thoughts with Healio by emailing the author at rschaffer@healio.com or posting on X (Twitter) @CardiologyToday. We will contact you if we wish to publish any part of your story.
References:
- Dankner R, et al. JAMA Netw Open. 2024;doi:10.1001/jamanetworkopen.2023.50408.
- de Lemos JA, et al. Hypertension. 2024;doi:10.1161/HYPERTENSIONAHA.123.22022
- Hall ME, et al. J Am Coll Cardiol. 2024;doi:10.1016/j.jacc.2023.11.033.
- Kong G, et al. Obesity. 2023;doi:10.1002/oby.23658.
- Schiavon CA, et al. J Am Coll Cardiol. 2024;doi:10.1016/j.jacc.2023.11.032.
- Shariq OA, et al. Gland Surg. 2020;doi:10.21037/gs.2019.12.03.
For more information:
Michael E. Hall, MD, MSc, can be reached at mehall@umc.edu; X (Twitter): @UMMC_MCCTR.
Sangeeta Kashyap, MD, can be reached at srk4008@med.cornell.edu; X (Twitter): @CleClinicMD.
Luke J. Laffin, MD, can be reached at laffinl@ccf.org; X (Twitter): @ljlaffin.
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