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The past decade has seen a shift in the strategy for hypertension treatment from stepped therapy--a highly structured monolithic series of steps--to recommendations for a more individualized selection of treatment. Severe hypertension is a clear indicator to bypass traditional steps. Demographic factors, such as age, gender, and race, are often cited, but have proved to be less helpful. Concomitant medical conditions and problems are very common and are more often the crucial determinants in the selection of antihypertensive therapy. Coronary artery disease, diabetes mellitus, heart failure, azotemia, asthma, and chronic obstructive pulmonary artery disease, anxiety, and depression are all common, and each has implications for the selection of antihypertensive therapy. Blood pressure reduction is a surrogate for reduction of cardiovascular risk, and therefore, consideration of concomitant medical problems has extended to left ventricular hypertrophy, obesity, mild hyperlipidemia, and insulin resistance, as additional risk factors in hypertension. Consideration of all these factors makes it possible to individualize antihypertensive therapy in most patients today.
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PMID:Treatment of hypertension: the place of angiotensin-converting enzyme inhibitors in the nineties. 128 28

To investigate the hypothesis that insulin resistance plays a role in the etiology of hypertension and hyperlipidemia, we measured serum lipid levels, the fasting glucose/insulin ratio, and the insulin response to oral glucose (GTT) in a group of young obese subjects (n = 21) with hypertension and normal glucose tolerance and in normotensive subjects (n = 36) with normal glucose tolerance, matched for age and body mass index. Leisure time physical activity was evaluated by a questionnaire outlining three levels of physical activities during leisure time. Subjects with hypertension had higher fasting serum insulin (19 +/- 2 v 13 +/- 1 microU/mL, P < .01) and lower fasting glucose/insulin ratio (5.3 +/- 0.2 v 7.1 +/- 0.5 mg/dL/microU/mL, P < .01) than normotensive subjects. Subjects with hypertension had higher peak serum insulin and lower plasma glucose area/insulin area ratio in response to glucose (1.8 +/- 0.2 v 2.4 +/- 0.2 mg/dL/microU/mL, P < .05) than normotensive subjects. Serum total cholesterol, low-density cholesterol, and triglycerides were higher in the obese hypertensive subjects than in obese normotensive ones. Blood pressure correlated with either fasting serum insulin, fasting glucose/insulin ratio, or glucose area/insulin area ratio during GTT. The level of leisure time physical activities was lower in obese hypertensive subjects than in obese normotensive ones. There were significant correlations between the levels of physical activity and the fasting plasma glucose/insulin ratio (r = 0.371, P < .01) or the fasting serum insulin concentration (r = -0.282, P < .05). The study provided evidence that a low level of leisure time physical activity is associated with insulin resistance and resultant hyperinsulinemia, which are the key metabolic abnormalities that link hypertension, obesity, and hyperlipidemia in young subjects.
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PMID:Leisure time physical activity and insulin resistance in young obese students with hypertension. 128 41

In an attempt to elucidate the role of the dietary fermentable fiber in reduction of hyperlipidemia, we substituted 30% wheat starch with 30% sugar-beet fiber in rats fed a fructose-based (41% fructose), low-fat (2% corn oil) diet. Male Wistar rats ate the test diets for 3 weeks. Feeding the sugar-beet fiber (SBF) diet resulted in a significant enlargement of the cecum; it also increased the concentration of volatile fatty acids compared with rats fed a fiber-free (FF) diet. Feeding SBF decreased plasma triglyceride and cholesterol concentrations in the postprandial as well as the postabsorptive period. In the liver, triglyceride levels were depressed in concert with the decreased liver lipogenesis and the post-Triton triglyceride secretion. Liver cholesterol levels were unaffected by SBF diet feeding. SBF-fed animals were markedly less fat compared with fiber-free-diet-fed rats. Adipose tissue lipogenesis was depressed in the postprandial period in SBF-fed animals. In short, this study suggests that substitution of easily digested carbohydrates by certain fermentable fibers may play an interesting role in the reduction of hyperlipidemia and obesity.
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PMID:Effects of dietary fermentable fiber on fatty acid synthesis and triglyceride secretion in rats fed fructose-based diet: studies with sugar-beet fiber. 131 52

The medical effects of modest weight reduction (approximately 10% or less) in patients with obesity-associated medical complications were reviewed. The National Library of Medicine MEDLINE database and the Derwent RINGDOC database were searched to identify English language studies that examined the effects of weight loss in obese patients with serious medical complications commonly associated with obesity (non-insulin dependent diabetes mellitus (NIDDM or type II), hypertension, hyperlipidemia, hypercholesterolemia, and cardiovascular disease). Studies in which patients experienced approximately 10% or less weight reduction were selected for review. Studies indicated that, for obese patients with NIDDM, hypertension or hyperlipidemia, modest weight reduction appeared to improve glycemic control, reduce blood pressure, and reduce cholesterol levels, respectively. Modest weight reduction also appeared to increase longevity in obese individuals. In conclusion, a large proportion of obese individuals with NIDDM, hypertension, and hyperlipidemia experienced positive health benefits with modest weight loss. For patients who are unable to attain and maintain substantial weight reduction, modest weight loss should be recommended; even a small amount of weight loss appears to benefit a substantial subset of obese patients.
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PMID:Beneficial health effects of modest weight loss. 132 66

A high plasma insulin concentration in the presence of a normal or high plasma glucose level appears to be a common feature of glucose intolerance, obesity, and hypertension. Hyperinsulinemia has been recognized as a major risk factor for the development of coronary artery disease independent of blood pressure and plasma lipid levels. All these conditions are frequently associated, particularly in aging, a state itself characterized by hyperinsulinemia. This common association has prompted the hypothesis that hyperinsulinemia may be a causative factor rather than the consequence of obesity, diabetes, hypertension, and hyperlipidemia. If that is the case, defining the nature and mechanisms of hyperinsulinemia becomes of primary interest. Insulin resistance is also a striking feature of all of the above mentioned pathologic states. In the presence of a preserved B-cell function, hyperinsulinemia can represent the mechanism designed to overcome the defect in the biological action of the hormone. For instance, there is a clear-cut age-related decline in the body's sensitivity to insulin. In order to compensate for this defect in insulin-mediated glucose metabolism, the B-cell must increase its secretion. On the other hand, a certain degree of insulin resistance can be induced both in animals and man by prolonged euglycemic hyperinsulinemia. Little is known regarding possible primary defects of the B-cell leading to uncontrolled oversecretion of insulin and subsequent insulin resistance. The primary defect, more probably, resides in an alteration of one or more of the steps whereby insulin exerts it own action. In favor of this hypothesis are the observations that insulin resistance segregates in familial clusters and that the first defect found in normoglycemic relatives of insulin-resistant diabetic patients is a reduced transformation of glucose into glycogen. Whatever is the primary defect, it is likely that a correction of insulin resistance might reduce the circulating levels of plasma insulin, possibly playing a beneficial effect on glucose tolerance, body weight, blood pressure and plasma lipid concentration.
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PMID:[Hyperinsulinism. Causes and mechanisms]. 133 21

Obesity is associated either with hepatic steatosis, a well known and innocuous entity or with non alcoholic steatohepatitis. This latter lesion has been recently individualized. It affects mainly middle-aged, obese women, with diabetes and/or hyperlipidaemia. It is morphologically very similar to alcoholic hepatitis. We review the literature considering 1) histologic hepatic lesions of the obese, 2) epidemiologic, clinical and biological characteristics of the non alcoholic steatohepatitis, 3) evolution and treatment of the non alcoholic steatohepatitis and 4) present physiopathological considerations. We conclude by considering the clinician's attitude in front of an obese potentially afflicted by a non alcoholic steatohepatitis.
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PMID:[Obesity: danger for the hepatocytes?]. 133 21

The combined syndrome of android (upper body) obesity, diabetes, hyperlipidaemia and hypertension is discussed in terms of a deranged endocrine regulation of metabolism. The syndrome is characterized by insulin insensitivity and an increased control of metabolism by cortisol. The antagonism between the two hormones appears to be partly responsible for the hyperglycaemia, hypertriglyceridaemia and hypercholesterolaemia. The synergism between insulin and cortisol in stimulating energy deposition, associated with a decreased effect of corticotropin-releasing factor in stimulating energy expenditure, is likely to contribute to the development of obesity. The efficacy of D-fenfluramine in treating the obese-diabetic-hyperlipidaemic-hypertensive syndrome probably depends on its actions on the serotoninergic system in the hypothalamus which both decreases food consumption and tends to normalize hormonal balance through the hypothalamic-pituitary-adrenal axis.
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PMID:Neuroendocrine regulation and obesity. 133 26

Current treatment of obesity seems to be focused mainly on the success of losing body weight, which can be achieved, in order of increasingly drastic manoeuvres: by simple nutritional advice; professional follow-up of a negative energy balance; drugs with effects on appetite regulation, energy absorption or expenditure; total seclusion with control of every administered calorie; surgical intervention; or even jaw-wiring. The only treatment of this sort that has been convincingly shown to have long-lasting effects is surgical intervention in the gastrointestinal tract, but this can only be accepted for use in severe cases. Thus, the problem of treatment of moderate obesity is to find an effective therapeutic modality which iss efficient in maintaining a reduced weight. Obesity treatment also seems to have focused too much on the mass of excess body fat, which is not necessarily an indicator of the medical hazards of the condition. It is important to realize that the risk factor clusters following obesity are often efficiently treated by successful reduction of the obese condition. Instead of specific treatment of each of these complications by, for example, multi-pharmacological therapy, a sufficiently efficient obesity treatment would be a preferable substitute. This goal may, if necessary, be achieved by treatment with a single drug with a useful therapeutic profile, including efficiency in the long-term to prevent relapse. Chronic treatment might then be considered acceptable in the same way as chronic pharmacological treatment of hypertension and hyperlipidemia, for example. No drug has as yet proven to have these characteristics.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Treatment of obesity. 133 27

The incidence of perioperative complications after coronary artery surgery was investigated by a retrospective study of all 502 patients undergoing coronary artery bypass graft (CABG) surgery in our Department between January 1st and December 31st of last year (1990). Furthermore, the influence of obesity on the early results of surgery was assessed and the effect of preoperative weight reduction on perioperative complication rates examined. Obese patients had a greater incidence of left-stem coronary artery stenosis (p less than 0.001), hyperlipidaemia (p less than 0.05), hypertension (p less than 0.05), diabetes mellitus (p less than 0.02), and were in general younger at the time of operation (57.9 +/- 8.4 vs. 60.8 +/- 8.5 years). There were no differences in the surgery performed and in operative mortality, but there were some in perioperative morbidity. Obese patients had higher rates of infection (p less than 0.02), sternal dehiscence (p less than 0.02), arrhythmias (p less than 0.02) and myocardial infarction (p less than 0.02). No significant differences were identified in obese patients with or without preoperative weight reduction, although there was a trend of better postoperative recovery and results in patients having undergone preoperative weight reduction. Analysis of our results demonstrated obesity to be an independent risk factor for perioperative complications, hospital morbidity, and length of hospitalization.
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PMID:The influence of obesity on perioperative morbidity: retrospective study of 502 aortocoronary bypass operations. 141 77

A major challenge in the United States is to narrow the gap in the excess morbidity and mortality rates of minority populations. This article presents a synthesis of the 15-year results of a collaborative program between the Johns Hopkins Medical Institutions and an African-American community with the highest rates of premature disease and death in Maryland. The program began with an efficacious disease prevention clinical trial with patients and ended with effective population approaches. We transferred key components to community ownership and formally trained community health workers who provided health promotion counseling, monitoring, linkage, and referral services. Results indicated significant decreases in morbidity and mortality as a result of improved control of hypertension. This program has begun to decrease the health status gap in an African-American population and has demonstrated long-term sustainability. Current joint activities are directed at several major causes of excess morbidity and mortality, including smoking, obesity, hyperlipidemia, and hypertension, and at plans for programs to control diabetes, substance abuse, and breast and cervical cancer.
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PMID:Narrowing the gap in health status of minority populations: a community-academic medical center partnership. 141 34


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