Effects of Bariatric Surgery in Obese Patients With Hypertension The effect of weight loss intervention on antihypertensive medication requirements in the hypertension Optimal Treatment (HOT) study. Obesity-related cardiovascular risk factors after weight loss: a clinical trial comparing gastric bypass surgery and intensive lifestyle intervention Body weight and blood pressure. Effects of weight reduction on hypertension. Obesity paradox in patients with hypertension and coronary artery disease. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. Long-Term Weight Loss and Changes in Blood Pressure: Results of the Trials of Hypertension Prevention, Phase II Treatment of Mild to Moderate Obesity with Laparoscopic Adjustable Gastric Banding or an Intensive Medical Program Bariatric Surgery versus Lifestyle Interventions for Morbid Obesity—Changes in Body Weight, Risk Factors and Comorbidities at 1 Year Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study. Obesity treatment for socioeconomically disadvantaged patients in primary care practice. How useful is weight reduction in the management of hypertension? Dieting to reduce body weight for controlling hypertension in adults. Multicenter evaluation of an interdisciplinary 52-week weight loss program for obesity with regard to body weight, comorbidities and quality of life—a prospective study Dietary therapy slows the return of hypertension after stopping prolonged medication. Body Weight, Weight Change, and Risk for Hypertension in Women Is weight loss an effective treatment for hypertension? The evidence against.
Background : Recent research efforts on bariatric surgery have focused on metabolic and diabetes mellitus resolution . R and omized trials design ed to assess the impact of bariatric surgery in patients with obesity and hypertension are needed . Methods : In this r and omized , single-center , nonblinded trial , we included patients with hypertension ( using ≥2 medications at maximum doses or > 2 at moderate doses ) and a body mass index between 30.0 and 39.9 kg/m2 . Patients  were r and omized to Roux-en-Y gastric bypass plus medical therapy or medical therapy alone . The primary end point was reduction of ≥30 % of the total number of antihypertensive medications while maintaining systolic and diastolic blood pressure < 140 mm Hg and 90 mm Hg , respectively , at 12 months . Results : We included 100 patients ( 70 % female , mean age 43.8±9.2 years , mean body mass index 36.9±2.7 kg/m2 ) , and 96 % completed follow-up .  Reduction of ≥30 % of the total number of antihypertensive medications while maintaining controlled blood pressure occurred in 41 of 49 patients from the gastric bypass group ( 83.7 % ) compared with 6 of 47 patients ( 12.8 % ) from the control group with a rate ratio of 6.6 ( 95 % confidence interval , 3.1–14.0 ; P<0.001 ) . Remission of hypertension was present in 25 of 49 ( 51 % ) and 22 of 48 ( 45.8 % ) patients r and omized to gastric bypass , considering office and 24-hour ambulatory blood pressure monitoring , respectively , whereas no patient su bmi tted to medical therapy was free of antihypertensive drugs at 12 months . A post hoc analysis for the primary end point considering the SPRINT ( Systolic Blood Pressure Intervention Trial ) target reached consistent results , with a rate ratio of 3.8 ( 95 % confidence interval , 1.4–10.6 ; P=0.005 ) . Eleven patients ( 22.4 % ) from the gastric bypass group and none in the control group were able to achieve SPRINT levels without antihypertensives . Waist circumference , body mass index , fasting plasma glucose , glycohemoglobin , low-density lipoprotein cholesterol , triglycerides , high-sensitivity C-reactive protein , and 10-year Framingham risk score were lower in the gastric bypass than in the control group . Conclusions : Bariatric surgery represents an effective strategy for blood pressure control in a broad population of patients with obesity and hypertension . Clinical Trial Registration : URL : https:// clinical trials.gov . Unique identifier : NCT01784848 Obesity is a significant risk factor for hypertension and the cardiovascular sequelae of hypertension . Weight loss has been shown to be effective in lowering blood pressure in overweight individuals . The purpose of this study was to show the impact of a weight loss intervention on overall medication requirements for obese , hypertensive patients . This was a sub study of the Hypertension Optimal Treatment ( HOT ) study . HOT study patients who had a body mass index > or = 27 kg/m2 were r and omized to receive either the weight loss intervention , which included dietary counseling and group support , or to serve as the control group . Patients ' weights and number of medication steps ( per HOT protocol ) required to achieve target diastolic blood pressure were measured at 3 , 6 , 12 , 18 , 24 , and 30 months . Patients in the weight loss group lost significantly more weight than the control group only at 6 months ( -3.2+/-4.3 v. -1.8+/-2.7 kg [ mean + /- SD ] for weight loss group versus control , respectively , P = .05 ) . The weight loss group tended to regain weight after the first 6 months of the study . However , patients in the weight loss group used a significantly fewer number of medication steps than the control group at all time intervals except 3 months . Weight loss appears to be a useful tool in blood pressure management in patients who require medication to control their blood pressure Objective Weight reduction improves several obesity-related health conditions . We aim ed to compare the effect of bariatric surgery and comprehensive lifestyle intervention on type 2 diabetes and obesity-related cardiovascular risk factors . Design One-year controlled clinical trial ( Clinical Trials.gov identifier NCT00273104 ) . Methods Morbidly obese subjects ( 19–66 years , mean ( s.d . ) body mass index 45.1 kg/m2 ( 5.6 ) , 103 women ) were treated with either Roux-en-Y gastric bypass surgery ( n=80 ) or intensive lifestyle intervention at a rehabilitation centre ( n=66 ) . The dropout rate within both groups was 5 % . Results Among the 76 completers in the surgery group and the 63 completers in the lifestyle group , mean ( s.d . ) 1-year weight loss was 30 % ( 8) and 8 % ( 9 ) respectively . Beneficial effects on glucose metabolism , blood pressure , lipids and low- grade inflammation were observed in both groups . Remission rates of type 2 diabetes and hypertension were significantly higher in the surgery group than the lifestyle intervention group ; 70 vs 33 % , P=0.027 , and 49 vs 23 % , P=0.016 . The improvements in glycaemic control and blood pressure were mediated by weight reduction . The surgery group experienced a significantly greater reduction in the prevalence of metabolic syndrome , albuminuria and electrocardiographic left ventricular hypertrophy than the lifestyle group . Gastrointestinal symptoms and symptomatic postpr and ial hypoglycaemia developed more frequently after gastric bypass surgery than after lifestyle intervention . There were no deaths . Conclusions Type 2 diabetes and obesity-related cardiovascular risk factors were improved after both treatment strategies . However , the improvements were greatest in those patients treated with gastric bypass surgery A sub study of the Hypertension Optimal Treatment study , conducted in the Jackson Mississippi Center , set out to determine the link between obesity and hypertension and to determine the effects of weight loss in hypertensive individuals . An analysis of the relationship between body mass index and diastolic blood pressure for another study showed that increasing body mass indices were associated with increases in blood pressure . This indicates that not only is there a strong relationship between obesity and hypertension , but that there is also a close association between the continuous variables of body mass index and blood pressure . The purpose of the present study was to determine the effectiveness of a weight loss regimen in reducing the amount of medication required to achieve the target blood pressure in 228 patients at the Jackson center . Subjects were r and omized to a dietary intervention group or to a control group .  Preliminary 3 month observational data showed that subjects who lost the appropriate amount of weight were three times more likely to achieve their target blood pressure at 3 months . These observations suggest that weight reduction regimens can reduce elevated blood pressure and can probably promote further blood pressure reductions when combined with drug therapy in the treatment of hypertension PURPOSE An obesity paradox , a " paradoxical " decrease in morbidity and mortality with increasing body mass index ( BMI ) , has been shown in patients with heart failure and those undergoing percutaneous coronary intervention . However , whether this phenomenon exists in patients with hypertension and coronary artery disease is not known . METHODS A total of 22,576 hypertensive patients with coronary artery disease ( follow-up 61,835 patient years , mean age 66+/-9.8 years ) were r and omized to a verapamil-SR or atenolol strategy . Dose titration and additional drugs ( tr and olapril and /or hydrochlorothiazide ) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure targets . Patients were classified into 5 groups according to baseline BMI : less than 20 kg/m2 ( thin ) , 20 to 25 kg/m2 ( normal weight ) , 25 to 30 kg/m2 ( overweight ) , 30 to 35 kg/m2 ( class I obesity ) , and 35 kg/m2 or more ( class II-III obesity ) . The primary outcome was first occurrence of death , nonfatal myocardial infa rct ion , or nonfatal stroke . RESULTS With patients of normal weight ( BMI 20 to<25 kg/m2 ) as the reference group , the risk of primary outcome was lower in the overweight patients ( adjusted hazard ratio [ HR ] 0.77 , 95 % confidence interval [ CI ] , 0.70 - 0.86 , P<.001 ) , class I obese patients ( adjusted HR 0.68 , 95 % CI , 0.59 - 0.78 , P<.001 ) , and class II to III obese patients ( adjusted HR 0.76 , 95 % CI , 0.65 - 0.88 , P < .001 ) . Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months ( -17.5+/-21.9 mm Hg/-9.8+/-12.4 mm Hg vs -20.7+/-23.1 mm Hg /-10.6+/-12.5 mm Hg , P<.001 ) . CONCLUSION In a population with hypertension and coronary artery disease , overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight , which was driven primarily by a decreased risk of all-cause mortality . Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention BACKGROUND Weight loss is associated with short-term amelioration and prevention of metabolic and cardiovascular risk , but whether these benefits persist over time is unknown . METHODS The prospect i ve , controlled Swedish Obese Subjects Study involved obese subjects who underwent gastric surgery and contemporaneously matched , conventionally treated obese control subjects . We now report follow-up data for subjects ( mean age , 48 years ; mean body-mass index , 41 ) who had been enrolled for at least 2 years ( 4047 subjects ) or 10 years ( 1703 subjects ) before the analysis ( January 1 , 2004 ) . The follow-up rate for laboratory examinations was 86.6 percent at 2 years and 74.5 percent at 10 years . RESULTS After two years , the weight had increased by 0.1 percent in the control group and had decreased by 23.4 percent in the surgery group ( P<0.001 ) . After 10 years , the weight had increased by 1.6 percent and decreased by 16.1 percent , respectively ( P<0.001 ) . Energy intake was lower and the proportion of physically active subjects higher in the surgery group than in the control group throughout the observation period . Two- and 10-year rates of recovery from diabetes , hypertriglyceridemia , low levels of high-density lipoprotein cholesterol , hypertension , and hyperuricemia were more favorable in the surgery group than in the control group , whereas recovery from hypercholesterolemia did not differ between the groups . The surgery group had lower 2- and 10-year incidence rates of diabetes , hypertriglyceridemia , and hyperuricemia than the control group ; differences between the groups in the incidence of hypercholesterolemia and hypertension were undetectable . CONCLUSIONS As compared with conventional therapy , bariatric surgery appears to be a viable option for the treatment of severe obesity , result ing in long-term weight loss , improved lifestyle , and , except for hypercholesterolemia , amelioration in risk factors that were elevated at baseline Approximately one fourth of the U.S. adult population nearly 50 million peoplehas hypertension ( 1 , 2 ) . Taking a broader perspective , more than half of the adult population has higher than optimal blood pressure ( 1 ) , defined as systolic blood pressure greater than 120 mm Hg and diastolic blood pressure greater than 80 mm Hg ( 2 ) . These persons are at significantly increased risk for cardiovascular disease and stroke ( 3 ) . Although pharmacologic treatment for hypertension significantly reduces morbidity and mortality from cardiovascular diseases ( 4 , 5 ) , long-term pharmacologic therapy can have undesirable side effects and requires the expense of continuing medical supervision . Furthermore , pharmacologic therapy is not usually initiated when blood pressure is higher than optimal yet below diagnostic thresholds for hypertension . Thus , lifestyle interventions for primary prevention and initial treatment of high blood pressure remain a vital strategy for controlling this highly prevalent condition ( 2 ) . Weight loss has been shown to reduce blood pressure in overweight hypertensive patients ( 6 - 9 ) and in overweight persons with high-normal blood pressure ( 10 - 12 ) . Two review s of r and omized trials of weight reduction to reduce blood pressure examined the results of nine studies ( 13 , 14 ) . Most of these trials were small , only one had more than 500 participants ( 11 ) , and most had short-term follow-up ( 1 year or less ) . Only three studies had follow-up of 3 to 5 years ( 8 , 10 , 11 ) . Compared with controls ,  weight loss  averaged nearly 7 kg in the short-term trials and approximately 3 kg in the three longer-term trials . In almost all trials , systolic blood pressure and diastolic blood pressure were reduced in the intervention groups . Since these review s were published , the Trials of Hypertension Prevention ( TOHP ) Phase I reported mean weight reduction of 3.9 kg at 18 months in 564 overweight participants with high-normal blood pressure , result ing in significant decreases in systolic blood pressure and diastolic blood pressure compared with a usual care control group ( 12 , 15 ) . To investigate whether nonpharmacologic interventions can prevent hypertension over the long term , TOHP II was initiated . This was a r and omized , controlled trial examining the effects of  weight loss and dietary sodium reduction , alone and in combination , in reducing blood pressure in overweight adults with high-normal diastolic blood pressure ( 16 ) . This target population is at high risk for hypertension as they age . The primary outcome paper from this trial ( 17 ) provided only a brief overview of the effects of weight loss on blood pressure . Here , we provide more detailed analysis of weight loss and blood pressure in TOHP II . Of special interest are the long-term effects of weight loss on blood pressure , the magnitude of the doseresponse relationship at 36 months , the effect of patterns of weight loss on blood pressure , and the predictors of weight loss and blood pressure response . Methods Participants Participants in TOHP II were overweight adults with nonmedicated diastolic blood pressure of 83 to 89 mm Hg and systolic blood pressure less than 140 mm Hg . Other eligibility criteria included age 30 to 54 years and a body mass index of 26.1 to 37.4 kg/m2 for men and 24.4 to 37.4 kg/m2 for women , approximately 110 % to 165 % of ideal weight ( 18 ) . Principal exclusion criteria were current treatment with medications that might affect blood pressure , clinical or laboratory evidence of cardiovascular disease , diabetes mellitus , renal insufficiency ( serum creatinine concentration 150 mol/L [ 1.7 mg/dL ] for men and 132 mol/L [ 1.5 mg/dL ] for women ) , and current or planned pregnancy . Detailed descriptions of recruitment and participant characteristics have been published elsewhere ( 19 , 20 ) . The study was review ed and approved by the institutional review boards at all nine TOHP centers and the coordinating center , and all participants signed informed consent forms . Design Eligible participants were r and omly assigned with equal probability to one of four groups : weight loss only , sodium reduction only , combined weight loss and sodium reduction , or usual care ( controls ) . Measurements Age , sex , ethnicity , and years of education were obtained by question naire . Baseline blood pressure measurements were taken at three screening visits , each separated by 7 to 45 days . At each visit , three readings of systolic blood pressure and diastolic blood pressure were obtained and averaged . Certified staff obtained measurements in seated participants by using a Hawksley r and om-zero sphygmomanometer ( 21 ) . Body weight was measured to the nearest 0.2 kg ( 0.5 lb ) by using a calibrated balance-beam scale ; participants wore indoor clothing ( without shoes ) . Blood pressure and weight were measured every 6 months after r and omization to the end of follow-up at 36 , 42 , or 48 months , depending on r and omization date . Clinic staff who were blinded to study group assignment made these assessment s. Blood pressure measurements were obtained during a single visit at all follow-up points except for 18 and 36 months , when measurements were taken at a series of three visits approximately 1 week apart . Multiple measurements were taken at 18 and 36 months to provide a more precise assessment of average blood pressures at these primary outcome points . Dietary intake was assessed by 24-hour recall , and physical activity was assessed by question naire . Intervention Participants assigned to the weight loss intervention group sought to lose at least 4.5 kg ( 10 lb ) during the first 6 months of the intervention and to maintain their weight loss for the remainder of the trial . A brief description of the intervention methods is presented here ; a more detailed description has been published elsewhere ( 22 ) . The intervention started with an individual counseling session , followed by 14 weekly group meetings led by dietitians or health educators . After this 14-week intensive phase , participants attended six biweekly group meetings and then monthly group meetings . Beginning in the 18th month , participants were offered a variety of options to keep them involved in the intervention , including individual counseling sessions and special group sessions focused on selected weight loss topics . The intervention focused on self-directed behavior change ( behavioral self-management ) , nutrition education , information on physical activity , and social support for making and maintaining behavior changes . Specific behavior change techniques included self-monitoring ( food diaries and graphs of minutes of physical activity per day ) , setting explicit short-term goals and developing specific action plans to achieve those objectives , and developing alternative strategies for situations that trigger problem eating . The dietary intervention focused on reducing caloric intake by decreasing consumption of excess fat , sugar , and alcohol . Keeping daily food diaries was emphasized for monitoring intake and assessing progress . With experience , the participants determined the caloric intake that produced moderate weight loss for them . It was suggested that men not consume less than 1500 kcal/d and women not less than 1200 kcal/d . Weight loss of more than 0.9 kg ( 2 lb ) per week was discouraged . The physical activity goal was to gradually increase activity to 30 to 45 minutes per day , four to five days per week . Exercise intensity was moderate , approximately 40 % to 55 % of heart rate reserve , and consisted primarily of brisk walking . Statistical Analysis Baseline characteristics of the weight loss and usual care groups were compared overall and by sex by using t-tests for means and chi-square tests for proportions . Although weight and blood pressure data were collected every 6 months , special efforts were made to achieve high follow-up rates at 18 and 36 months ; at each of these two time points , nine blood pressure readings were collected over three visits and were averaged . For participants prescribed antihypertensive medication , follow-up blood pressure for all subsequent visits was taken to be the last study blood pressure before therapy was started . Participants receiving medications that affect blood pressure for reasons other than hypertension or who became pregnant were treated as missing at that visit . We used two- sample t-tests to compare changes in weight and blood pressure from baseline in the  weight loss intervention and usual care groups overall , by sex , by ethnicity , and by sex and ethnicity . The effects of the intervention in terms of changes in weight and blood pressure were examined overall and in subgroups defined by sex , ethnicity , and sex and ethnicity . Subgroup differences were tested by using terms for the interaction of treatment group with sex and with ethnicity in multiple linear regression models . Regression analyses were also used to analyze the doseresponse relationship between change in weight and change in blood pressure , overall and within sex and ethnicity subgroups . Differences in dose response were tested by using interaction terms in linear regression models . All regressions were adjusted for age and baseline weight . We also adjusted for baseline blood pressure in the blood pressure regression models . Change in blood pressure was also examined in relation to quintile of weight loss . Quintiles were computed by using the distribution of weight change in the weight loss intervention group . Additional multiple regression analyses were performed in which weight loss participants were categorized according to patterns of weight loss at 6 and 36 months . The PROC MIXED function of SAS software ( SAS Institute , Inc. , Cary , North Carolina ) was used to perform repeated- measures analyses that tested differences over time by pattern of weight loss . Cox proportional-hazards models were used for survival analyses , with onset of hypertension as the outcome . Results Baseline Findings The baseline characteristics of participants assigned to Context Observational studies have shown sustained weight loss after surgery for extreme obesity . No r and omized trial of contemporary surgical methods has been performed . Contribution The authors r and omly assigned 80 mildly to moderately obese ( body mass index , 30 to 35 kg/m2 ) adults to laparoscopic placement of an adjustable gastric b and or to an intensive nonsurgical weight loss program . After 2 years , the surgical group had lost 21.6 % of initial weight , and the nonsurgical group had lost 5.5 % of initial weight . Four patients required laparoscopic revision of the gastric b and . Caution s The study was not design ed to detect uncommon adverse events . Implication s Laparoscopic gastric b and ing is effective treatment for mild to moderate obesity . The Editors The development of a safe and effective treatment for obesity is a leading challenge in health care today . Obesity is an increasing health problem across the world with a prevalence of more than 20 % among the adult population in Western countries and more than 30 % in the United States ( 1 , 2 ) . The increasing prevalence is associated with a parallel increase of several obesity-related diseases , in particular , the diseases of the metabolic syndrome ( 3 , 4 ) , which include type 2 diabetes , hypertension , and dyslipidemia , and are linked to nonalcoholic steatohepatitis , obstructive sleep apnea , and the polycystic ovary syndrome . For obese individuals , the options are limited . Behavioral therapies of reduced energy intake , improved eating practice s , and increased exercise and activity , supplemented by pharmacotherapy , generally achieve only modest and often transient effects ( 5 , 6 ) . Observational studies have shown that bariatric surgical therapies involving gastric restriction by various forms of stapling with or without diversion of the gut to generate malabsorption of food are effective in achieving major weight loss and clinical ly significant improvements in health and quality of life ( 7 - 11 ) . Strong direct evidence from r and omized , controlled trials of the relative benefits of nonsurgical and surgical therapies is lacking . We are aware of only a single study , performed in the 1980s , in which 60 morbidly obese patients were r and omly assigned , without informed consent , to diet plus an early form of gastric stapling or to diet alone ( 12 ) . The maximum weight losses did not differ between the groups . However , the weight regain was greater in the diet-only group . The advent of the laparoscopic adjustable gastric b and has provided a new bariatric surgical option , which has proved to be safe , minimally invasive in its application , gentle in its use through its adjustability and easy reversibility , and similarly effective to the other bariatric procedures ( 10 , 13 , 14 ) . Figure 1 shows the LAP-B AND System ( INAMED Health , Santa Barbara , California ) and demonstrates the key feature of adjustability of the area within the b and through which it induces satiety ( 15 ) . Patients require no more than an overnight hospital stay , and the procedure has been shown to be markedly safer than gastric bypass surgery ( 13 ) . Figure 1 . The laparoscopic adjustable gastric b and ( LAP-B AND System , INAMED Health , Santa Barbara , California ) with no added fluid ( top ) and with 2 mL of fluid added ( bottom ) . We hypothesized that surgical therapy would induce more weight loss , health benefit , and improvement in quality of life than nonsurgical therapy and have conducted a r and omized , controlled trial comparing the effectiveness of current nonsurgical therapy with laparoscopic adjustable gastric b and ing in a group of mildly to moderately obese adults ( body mass index , 30 kg/m2 to 35 kg/m2 ) . We did not study patients with a body mass index greater than 35 kg/m2 because current observational data suggest that outcomes after nonsurgical treatment were unlikely to be equal to those after surgical care for these patients . The principal outcome measures were weight change , health , quality of life , and complications of therapy . Methods Patient Recruitment We recruited patients for the study through a newspaper advertisement . All patient assessment s and outpatient treatments were conducted at a community clinic dedicated to obesity management or in the clinics of a university department of surgery . Surgical procedures were conducted at a private community hospital experienced in the care of bariatric surgical patients . Patients in both groups did not pay any medical costs generated by the study . The human ethics committees of The Alfred Hospital and The Avenue Hospital approved the study in accordance with the guidelines of the National Health and Medical Research Council ( www.nhmrc.gov.au/publications/synopses/e35syn.htm ) and with the Helsinki Declaration of 1975 , as revised in 2000 ( www.wma.net/e/ethicsunit/pdf/draft_historical_contemporary_perspectives.pdf ) . Inclusion Criteria We considered patients to be eligible if they were between 20 and 50 years of age ; had a body mass index of 30 kg/m2 to 35 kg/m2 ; had identifiable problems , including an obesity-related comorbid condition ( such as hypertension , dyslipidemia , diabetes , obstructive sleep apnea , or gastroesophageal reflux disease ) , severe physical limitations , or clinical ly significant psychosocial problems associated with their obesity ; had attempted to reduce weight over at least the previous 5 years ; could underst and the options offered and the r and omization process ; and were willing to comply with the requirements of each program . Exclusion Criteria We excluded c and i date s with a history of bariatric surgery or medical problems that contraindicated treatment in either study group , such as impaired mental status , drug or alcohol addiction , or portal hypertension . In addition , we excluded participants if they had undergone an intensive , physician-supervised program that used very-low-calorie diets or pharmacotherapy or if they did not attend the 2 initial patient information visits . Assessment We provided detailed information about the problems of obesity and about the 2 study groups through at least 2 discussion periods and a patient information booklet . Initial assessment included anthropometric measures ; identification of medical , physical , or psychosocial problems ( both weight-related and other ) ; and a discussion of previous weight loss efforts . The assessment included a detailed dietary history by the trial dietitian and a review by a specialist physician to determine the presence and severity of associated medical conditions . Initial investigations included measurements of fasting blood glucose level ; serum insulin level ; and a lipid profile , including HDL cholesterol and LDL cholesterol levels . After initial assessment , we instituted a program of advice on appropriate eating patterns and exercise and followed each patient on a monthly basis for 3 months . During this time , we assessed the patients ' fulfillment of tasks , such as completion of a food diary , and overall adherence to appointments . R and omization Process We r and omly allocated eligible patients to receive a conventional , intensive , nonsurgical program or laparoscopic adjustable gastric b and ing .  A computer-derived r and om allocation sequence , without blocking or stratification , performed the r and omization . This was prepared at the trial office . The trial coordinator enrolled participants and informed them of the trial allocation . After assessment had confirmed a participant 's suitability for r and omization , the coordinator contacted the trial office by telephone for allocation . The study was not blinded . Description of Nonsurgical and Surgical Interventions Common Program We instructed and encouraged all patients to follow appropriate lifestyle behavior of good eating practice s and increased exercise and activity . We also encouraged them to exercise for at least 200 minutes per week . Nonsurgical Program This program centered on the use of behavioral modification , very-low-calorie diet , and pharmacotherapy with education and professional support on appropriate eating and exercise behavior . During the 2-year period , 3 trained physicians developed a program using all the available modalities for each individual on the basis of guidelines prepared and continually review ed by a panel of experienced bariatric physicians . The program began with an intensive 6-month period of very-low-calorie diet ( 500 to 550 kcal/d ) using 1 to 3 packets of Optifast ( Novartis , Fremont , Michigan ) daily for 12 weeks , followed by a transition phase over 4 weeks combining some very-low-calorie meals with 120 mg of orlistat before nonvery-low-calorie diet meals , and then 120 mg of orlistat before all meals until the completion of the intensive phase . This intensive 6-month program was followed by further courses of very-low-calorie diets or orlistat as tolerated , as well as continual behavioral , dietary , and exercise advice to assist the participant in maintaining weight loss over a prolonged period . Sibutramine was not approved for use in Australia during the first 12 months of the study and , therefore , was not incorporated into the medical program . The management program for each individual was design ed to reflect good clinical practice . A physician saw each patient every 2 weeks during the very-low-calorie diet program and every 4 to 6 weeks during the rest of the study . All patients were seen at least every 6 weeks . Surgical Program Two experienced surgeons performed the laparoscopic adjustable gastric b and ( LAP-B AND System ) procedure , by a st and ardized method ( 14 ) , within 1 month of r and omization . The b and was placed along the perigastric pathway in all cases ( 16 ) . The treating surgeon review ed patient progress every 4 to 6 weeks during the study period and made adjustments to the volume of saline within the b and in the office by using st and ard clinical criteria ( 17 ) . Adverse Events All patients in the study were question ed about the occurrence of adverse events at each consultation , and physicians recorded the Background Few studies have looked at non-surgical alternatives for morbid obese patients . This study aims to compare 1-year weight loss and changes in risk factors and comorbidities after bariatric surgery and three conservative treatments . Methods Patients with morbid obesity ( BMI > 40 or BMI > 35 kg/m2 plus comorbidities ) on waiting list for bariatric surgery  , were non-r and omly allocated to ( A ) bariatric surgery or to one of three conservative treatments ; ( B ) residential intermittent program ; ( C ) commercial weight loss camp and ( D ) hospital outpatient program . Body weight , risk factors and comorbidities were assessed at baseline and 1 year . Results Of 206 participants , 179 completed the study . All treatments result ed in significant weight loss , but bariatric surgery ( 40 ± 14 kg , 31 ± 9 % ) led to the largest weight loss ( P < 0.0001 ) . There were no differences in weight loss between B and C ( 22 ± 13 kg , 15 ± 8 % vs. 18 ± 12 kg , 13 ± 8 % ) , but these result ed in larger weight loss compared with D ( 7 ± 10 kg , 5 ± 8 % ) . There were no differences in changes in total or LDL cholesterol , triacylglycerols or glucose between groups ; however , the increase in HDL cholesterol was significantly larger in groups A and C. There were no differences in comorbidities resolution between groups A and B , C and D combined ( except hypertension , which was better in group A ) . Conclusion In conclusion , although bariatric surgery leads to a greater weight loss at 1 year compared with conservative treatment , in patients with morbid obesity , clinical significant weight loss and similar improvements in risk factors and comorbidities resolution can also be achieved with lifestyle interventions OBJECTIVE To examine the effect of a large , long st and ing and intentional weight reduction on the incidence of diabetes , hypertension and lipid disturbances in severely obese individuals as compared to weight-stable obese controls . RESEARCH METHODS AND PROCEDURES The ongoing prospect i ve SOS ( Swedish Obese Subjects ) intervention consists of a surgically treated group and a matched control group obtaining conventional obesity treatment . This report is based on 845 surgically treated patients and 845 controls ( BMI 41.0+/-4.6 kg/m2 ( mean+/-st and ard deviation [ S ] ) ) followed for 2 years . RESULTS Surgically treated patients lost 28+/-15 kg and controls 0.5+/-8.9 kg ( p<0.0001 ) . Two-year incidence of hypertension , diabetes , hyperinsulinemia , and lipid disturbances was compared in the two treatment groups . Adjusted odds ratios ( 95 % CI ) for the surgically treated group versus controls were 0.38 ( 0.22 , 0.65 ) for hypertension , 0.02 ( 0.00 , 0.16 ) for diabetes , 0.10 ( 0.03 , 0.28 ) for hyperinsulinemia , 0 . 10 ( 0.04 , 0.25 ) for hypertriglyceridemia , 0.28 ( 0.16 , 0.49 ) for low HDL-cholesterol and 1.24 ( 0.84 , 1.8 ) for hypercholesterolemia . Compared to controls , the 2-year recovery rates from hypertension , diabetes , hypo-HDL , and hypertriglyceridemia were significantly higher in the surgically treated group . DISCUSSION Intentional weight loss in the obese causes a marked reduction in the 2-year incidence of hypertension , diabetes and some lipid disturbances . The results suggest that severe obesity can and should be treated BACKGROUND Few evidence -based weight loss treatment options exist for medically vulnerable patients in the primary care setting . METHODS We conducted a 2-arm , 24-month r and omized effectiveness trial in 3 Boston community health centers ( from February 1 , 2008 , through May 2 , 2011 ) . Participants were 365 obese patients receiving hypertension treatment ( 71.2 % black , 13.1 % Hispanic , 68.5 % female , and 32.9 % with less than a high school educational level ) . We r and omized participants to usual care or a behavioral intervention that promoted weight loss and hypertension self-management using eHealth components . The intervention included tailored behavior change goals , self-monitoring , and skills training , available via a website or interactive voice response ; 18 telephone counseling calls ; primary care provider endorsement ; 12 optional group support sessions ; and links with community re sources . RESULTS At 24 months , weight change in the intervention group compared with that in the usual care group was -1.03 kg ( 95 % CI , -2.03 to -0.03 kg ) . Twenty-four-month change in body mass index ( calculated as weight in kilograms divided by height in meters squared ) in the intervention group compared with that in the usual care group was -0.38 ( 95 % CI , -0.75 to -0.004 ) . Intervention participants had larger mean weight losses during the 24 months compared with that in the usual care group ( area under the receiver operating characteristic curve , -1.07 kg ; 95 % CI , -1.94 to -0.22 ) . Mean systolic blood pressure was not significantly lower in the intervention arm compared with the usual care arm . CONCLUSION The intervention produced modest weight losses , improved blood pressure control , and slowed systolic blood pressure increases in this high-risk , socioeconomically disadvantaged patient population . Trial Registration clinical trials.gov Identifier : NCT00661817 A group of previously untreated obese hypertensive patients were started on a weight reduction programme supervised by two dietitians working in a general practice surgery . It was stressed from the beginning of the programme that reducing blood pressure was the purpose of the diet . The results of follow-up after six months are presented together with results for a control group of obese hypertensive patients not receiving dietary advice or drug therapy , but being followed by the general practitioner . The weight , systolic blood pressure and diastolic blood pressure of the dieting hypertensive group were significantly lower than those of the non-dieting group after six months . However , the drop-out rate was significantly higher for the dieting group than for the non-dieting group . The results of a separate comparison between a control group of obese normotensive patients following the same dietary programme and the group of dieting obese hypertensive patients are also presented . Attendance rates and weight loss achieved were significantly better for the hypertensive group than for the normotensive group after 12 months . Weight reduction appears to be an effective first-line therapy for approximately 50 % of obese patients with mild to moderate hypertension , and raised blood pressure appears to provide motivation for such patients to attend a dietitian 's clinic and to lose weight OBJECTIVES : Evaluate whether weight-loss diets are more effective than regular diets or other antihypertensive therapies in controlling blood pressure and preventing morbidity and mortality  in hypertensive adults . SEARCH STRATEGY : MEDLINE and The Cochrane Library were search ed through November 1997 . Trials known to experts in the field were included through June 1998 . SELECTION CRITERIA : For inclusion in the review , trials were required to meet each of the following criteria : 1 ) r and omized controlled trials with one group assigned to a weight-loss diet and the other group assigned to either normal diet or antihypertensive therapy ; 2 ) ambulatory adults with a mean blood pressure of at least 140 mm Hg systolic and /or 90 mm Hg diastolic ; 3 ) active intervention consisting of a  calorie-restricted diet intended to produce weight loss ( excluded studies simultaneously implementing multiple lifestyle interventions where the effects of weight loss could not be disaggregated ) ; and 4 ) outcome measures included weight loss and blood pressure . DATA COLLECTION AND ANALYSIS : Studies were dual abstract ed by two independent review ers using a st and ardized form design ed specifically for this review . The primary mode of analysis was qualitative ; graphs of effect sizes for individual studies were also used . MAIN RESULTS : Eighteen trials were found . Only one small study of inadequate power reported morbidity and mortality outcomes . None addressed quality of life or general well being issues . In general , participants assigned to weight-reduction groups lost weight compared to control groups . Six trials involving 361 participants assessed a weight-reducing diet versus a normal diet . The data suggested weight loss in the range of 4 % to 8 % of body weight was associated with a decrease in blood pressure in the range of 3 mm Hg systolic and diastolic . Three trials involving 363 participants assessed a weight-reducing diet versus treatment with antihypertensive medications . These suggested that a stepped-care approach with antihypertensive medications produced greater decreases in blood pressure ( in the range of 6/5 mm Hg systolic/diastolic ) than did a weight-loss diet . Trials that allowed adjustment of participants ' antihypertensive regimens suggested that patients required less intensive antihypertensive drug therapy if they followed a weight-reducing diet . Data was insufficient to determine the relative efficacy of weight-reduction versus changes in sodium or potassium intake or exercise . REVIEW ER 'S CONCLUSIONS : Weight-reducing diets in overweight hypertensive persons can affect modest weight loss in the range of 3 - 9 % of body weight and are probably associated with modest blood pressure decreases of roughly 3 mm Hg systolic and diastolic . Weight-reducing diets may decrease dosage requirements of persons taking antihypertensive medications Objectives : To determine the effectiveness of a structured multidisciplinary non-surgical obesity therapy program on the basis of a temporary low-calorie-diet for 12 weeks , and additional intervention modules to enhance nutritional education , to increase physical activity and to modify eating behavior . Design : Prospect i ve multicenter observational study in obese individuals undergoing a medically supervised outpatient-based 52-week treatment in 37 centers in Germany . Subjects : A total of 8296 participants with a body mass index ( BMI ) of > 30 kg m−2 included within 8.5 years . Measurements : Main outcome measures were body weight loss , waist circumference ( WC ) , blood pressure , quality of life and adverse events . Results : In females , initial body weight was reduced after the 1-year-intervention by 19.6 kg ( 95 % confidence intervals 19.2–19.9 kg ) and in males by 26.0 kg ( 25.2–26.8 ) according to per protocol analysis of 4850 individuals . Intention-to-treat ( ITT ) analysis revealed a weight reduction of 15.2 kg ( 14.9–15.6 ) in females and 19.4 kg ( 18.7–20.1 ) in males . Overall , the intervention result ed in mean reduction in WC of 11 cm ; it reduced the prevalence of the metabolic syndrome by 50 % and the frequency of hypertension from 47 to 29 % of all participants ( ITT , all P<0.001 ) . The beneficial effects could be documented for up to 3 years and comprised significant improvement of health-related quality of life . The incidence of adverse effects was low ; the only event repeatedly observed and possibly related to either the intervention or the underlying disease was biliary disorders . Conclusion : The present non-surgical intervention program is a highly effective treatment of obesity grade s I – III and obesity-related diseases , and therefore , could be a valuable basis for future weight maintenance strategies required for sustained success This study asks whether prolonged antihypertensive therapy will " cure " a substantial percent of rigorously treated hypertensive patients and whether nutritional change will add an antihypertensive effect and reduce the relapse rate . Of 584 eligible patients normotensive while receiving therapy , 496 were r and omized into control and discontinued-medication groups with and without dietary intervention . At 56 weeks , 50 % of those who were no longer receiving medication remained normotensive by study criteria . R and omization either to weight-loss group ( mean loss of 4.5 kg [ 10 lb ] ) or to sodium-restriction group ( mean reduction of 40 mEq/day ) increased the likelihood of remaining without drug therapy , with an adjusted odds ratio of 2.17 for the sodium group and 3.43 for the weight group . Highest success rates were in the nonoverweight mild hypertensives with sodium restriction ( 78 % ) and the overweight mild hypertensives who were reducing their weight ( 72 % ) . These data demonstrate that weight loss or sodium restriction , in hypertensives controlled for five years , more than doubles success in withdrawal of drug therapy Most cross-sectional studies have shown an association between obesity and hypertension , and the prevalence of hypertension seems to increase with the degree of obesity [ 1 , 2 ] . In prospect i ve studies , obesity has been strongly related to future risk for hypertension [ 3 - 5 ] . Several clinical trials have found that short-term weight loss reduces blood pressure in hypertensive patients or persons with high normal blood pressure [ 6 - 8 ] . However , the long-term efficacy of this approach for controlling blood pressure is not well established . Because treating hypertension over a long period is costly [ 9 ] , the best approach for the control of hypertension in the general population is primary prevention . The degree to which long-term weight loss effectively prevents or delays the onset of hypertension in a normotensive population has important public health implication s. We prospect ively investigated  body mass index ( BMI ) at 18 years of age and at midlife , as well as long-term and medium-term weight changes , in relation to subsequent risk for hypertension in a large cohort of U.S. female nurses without diagnosed hypertension at baseline . In a previous analysis of this cohort [ 10 ] , higher BMI at midlife strongly increased the risk for developing hypertension during the subsequent 4 years of follow-up . However , this analysis did not examine BMI in early adulthood and weight changes in relation to the occurrence of hypertension . In the present analysis , we extended the follow-up to 16 years and included 13 120 additional incident cases of hypertension . The substantially greater power of this study allowed us to investigate the association of weight change with risk for hypertension and to examine whether weight loss could more effectively prevent hypertension in subgroups of the population ( especially those defined by baseline BMI and age ) . Methods The Nurses ' Health Study is a long-term follow-up study of female registered nurses who were 30 to 55 years of age at study entry . In 1976 , 121 700 nurses responded to a mailed question naire on medical history and health behaviors . Follow-up question naires have been sent to participants every 2 years to identify incident diagnoses of hypertension and other medical events and to up date information on risk factors . Further details have been reported elsewhere [ 11 ] . As of 1 June 1992 , the follow-up rate was 95 % of potential person-years . For the current analysis , we excluded women who , at baseline , reported high blood pressure ( or use of antihypertensive medications ) or a history of myocardial infa rct ion , angina pectoris , stroke , coronary artery surgery , diabetes mellitus , or any cancer other than nonmelanoma skin cancer ( n = 19 654 ) . If any of these conditions developed during follow-up , the women were excluded from subsequent follow-up intervals . We also excluded women for whom information on height ( n = 127 ) or weight at age 18 years ( n = 19 447 ) was missing . The analytic cohort consisted of 82 473 women . Measurement of Exposures The baseline question naire solicited information on age , current weight , height , parity , oral contraceptive use , smoking status , family history of myocardial infa rct ion , menopausal status , postmenopausal use of hormones , and other variables . Up date d information on most of these variables was collected on biennial follow-up question naires . In 1980 , we asked participants about weight at 18 years of age and current alcohol consumption . Starting in 1986 , we assessed the level of physical activity  in detail . Body mass index was used as a measure of obesity . Current BMI was up date d every 2 years by using the most recent body weight . Women were categorized into 10 groups by using whole-number cut-points of current BMI and by deciles of BMI at age 18 years to provide a reasonable number of participants in each category . The lowest category was used as the referent . We calculated long-term weight changes ( from 18 years of age to the beginning of each 2-year follow-up interval ) and medium-term weight changes ( from 1976 to the beginning of each 2-year follow-up interval ) . Women were divided into nine groups : weight loss of 10 kg or more , loss of 5.0 to 9.9 kg , loss of 2.1 to 4.9 kg , loss or gain of 2.0 kg or less , gain of 2.1 to 4.9 kg , gain of 5.0 to 9.9 kg , gain of 10.0 to 19.9 kg , gain of 20.0 to 24.9 kg , and gain of 25 kg or more . The stable weight group ( loss or gain 2.0 kg ) was the referent . For medium-term weight change , we examined the effects of weight loss sustained for a longer period by grouping women according to weight changes from 1976 to the beginning of the current interval and from 1976 to the beginning of the previous interval . Thus , in this analysis , women were categorized into a specific weight-change group only if their weight changes from 1976 to the current interval and to the previous interval fell into the same category . Otherwise , they were classified into an unstable weight group . In a sub sample of 184 participants living in the Boston area , self-reported weights were highly correlated with measured weights ( r = 0.96 ; mean difference , 1.5 kg ) [ 12 ] . In another sample of 118 younger nurses aged 25 to 42 years , recalled weights at 18 years of age were highly correlated with weights at 17 to 21 years of age that were recorded on nursing-school physical examination forms ( r = 0.87 ; mean difference , 1.4 kg ) [ 13 ] . Ascertainment of Hypertension Incident cases of hypertension were identified by self-reports of physician-diagnosed high blood pressure . On biennial follow-up question naires , we asked whether high blood pressure ( except that occurring during pregnancy ) had been diagnosed by a physician and , if so , the date of diagnosis . By 1992 , 16 395 incident cases of hypertension had been diagnosed . The validity of self-reported diagnosis of hypertension was assessed in a r and om sample of 100 nurses who had reported a diagnosis of high blood pressure on the 1982 question naire [ 14 ] . Of the 85 women who responded to a supplementary question naire , all but 1 confirmed their previous reports of hypertension ; 62 of the 85 women gave written permission for review of their medical records . We obtained records for 51 women ; all of them had  blood pressure measurements  higher than 140/90 mm Hg , and 39 ( 77 % ) had blood pressure measurements greater than 160/95 mm Hg . To investigate the likelihood of false-negative responses , blood pressure was measured in another sample of 194 nurses living in the Boston area . Among the 161 women without a previous self-report of hypertension , 7 % had a blood pressure higher than 140/90 mm Hg but none had a blood pressure greater than 160/95 mm Hg . In addition , self-reported physician diagnosis of hypertension is a strong predictor of myocardial infa rct ion and stroke in this cohort [ 15 ] ; this finding provided further biological evidence that the self-reported diagnosis of hypertension is a valid measure in our study . Statistical Analysis Follow-up started in 1976 when the baseline question naire was returned ; follow-up time accrued until the date of diagnosis of hypertension , use of antihypertensive medications , myocardial infa rct ion , angina pectoris , coronary artery surgery , stroke , diabetes mellitus , any cancer other than nonmelanoma skin cancer , death , or 1 June 1992 , whichever came first . Women were not included in the analysis during an interval if information on their current weight was missing or if they had been pregnant for at least 6 months during the previous 2-year interval . These women , however , could reenter the analyses in the subsequent follow-up intervals . Relative risk was used as the measure of association and was computed as the incidence in a specific category of BMI or weight change divided by the rate in the reference category . We used proportional hazards analyses to compute age-adjusted and multivariate-adjusted relative risks with 95 % CIs [ 16 , 17 ] . Weight change and BMI were treated as continuous variables in the models to test linear trends and to compute relative risks for each one-unit increase in BMI and weight change . We calculated the population attributable risk percentages that were attributable to long-term and medium-term weight gain compared with weight change of 2 kg or less [ 18 ] . Stratified analyses were performed to examine whether age and baseline BMI modified the relation between weight change and risk for hypertension . Role of Study Sponsors Amgen , Inc. , approved the proposal for data analysis but was not involved in analyzing , interpreting , or reporting the data . Results By 1992 , 16 395 incident cases of hypertension had been diagnosed during 923 544 person-years of follow-up . In an age-adjusted analysis , higher current BMI was strongly associated with an increasing risk for hypertension ( Table 1 ) . This association was not altered after adjustment for height , family history of myocardial infa rct ion , parity , oral contraceptive use , menopausal status , postmenopausal use of hormones , and cigarette smoking . Compared with women who had a BMI less than 20 kg/m ( 2 ) , women with a BMI of 31 kg/m2 or more had a multivariate relative risk of 6.31 ( 95 % CI , 5.80 to 6.87 ) . This increase in risk for hypertension was monotonic with BMI ; even for women with a BMI of 20.0 to 20.9 kg/m2 , the risk was significantly elevated ( relative risk , 1.15 [ CI , 1.04 to 1.27 ] ) . In the multivariate model in which BMI was treated as a continuous variable , an increase in BMI of 1 kg/m2 was associated with a 12 % increase in risk for hypertension . Table 1 . Relative Risk for Subsequent Hypertension according to Body Mass Index * Higher BMI at 18 years of age was associated with an increased risk for hypertension later in life after we controlled for age , subsequent weight change , and other covariates ( P for trend < 0.001 ) . Women whose BMI at 18 years of age was greater than 25 kg/m2 had a relative risk of 2.28 ( CI , 2.12 to 2.45 ) compared with women whose BMI at 18 years of age was 18.2 kg/m2 or less . The increase in risk Although there are many studies reporting correlations between relative body weight and blood pressure , the correlations are generally of low order . Furthermore , these observational studies provide , at best , circumstantial evidence concerning the effect of weight reduction on elevated blood pressure . After outlining key method ologic criteria for testing the hypothesis that weight loss lowers blood pressure among hypertensive obese subjects , this article review s the best intervention studies that are available . Despite the demonstration in these r and omized trials that weight reduction programs can lower weight successfully , the results for blood pressure lowering are in considerable disagreement . Two studies reported significant lowering of both systolic and diastolic blood pressure , one found significant lowering of systolic pressure only , and two failed to find significant differences in either . The definitive study of substantial weight loss among patients receiving no other antihypertensive treatment or st and ardized medical treatment with long-term follow-up has yet to be done . At best , weight loss offers very limited benefit for overweight hypertensives . At worst , weight loss programs are expensive to run , cause considerable patient discomfort and may delay the implementation of more effective therapy
Evidence suggests significant improvement in obesity-hypertension in patients who undergo surgical weight-reduction procedures .
Malabsorptive techniques such as the Roux-en-Y gastric bypass or surgical resection techniques such as laparoscopic sleeve gastrectomy appear to offer superior results in regards to hypertension control over restrictive techniques such as Gastric B and ing .
Though long-term control of hypertension following surgery remains a concern , available follow-up post-operative data of up to 10 years suggests a sustained , if lessened , effect on hypertension control over time
Obesity continues to increase in prevalence worldwide .
Hypertension has long been associated with obesity , and weight loss continues to be a first-line therapy in the treatment of hypertension .
Lifestyle modification and pharmacologic therapy , however , often meet with treatment failure .
Bariatric surgery continues to be the most successful approach to sustained weight loss .
This review focuses on the underlying physiologic mechanisms of obesity-hypertension , and the impact of bariatric surgery on the treatment of hypertension .