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(Hypertension. 1996;27:125-129.)
© 1996 American Heart Association, Inc.
Articles |
Decrease in Intra-Abdominal Visceral Fat May Reduce Blood Pressure in Obese Hypertensive Women
From The Division of Internal Medicine, Toyonaka Municipal Hospital (H.K.), and The Second Department of Internal Medicine, Osaka (Japan) University Medical School.
Correspondence to Hideyuki Kanai, MD, The Division of Internal Medicine, Toyonaka Municipal Hospital, 2-1-1 Okakaminocho, Toyonaka City, Osaka 560, Japan.
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Abstract |
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 Top Abstract IntroductionMethods Results Discussion References |
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Abstract We investigated the relationship between changes in blood pressure and fat distribution after a 12-week low-calorie diet in 26 obese hypertensive women whose average age was 50±13 years, mean body mass index was 33.7±3.1 kg/m2, and mean blood pressure was 112±9 mm Hg. As an index of intra-abdominal fat accumulation, we used the ratio of the intra-abdominal visceral fat area to subcutaneous fat area, determined by a computed tomographic section at the level of the umbilicus. Subjects lost a mean of 9.4±4.1 kg on a 1200-kcal (5040-kJ) diet for 12 weeks. Their mean blood pressure fell from 112±9 to 101±12 mm Hg (P<.001). The ratio of the visceral to subcutaneous fat area was significantly reduced after weight reduction from 0.56±0.33 to 0.45±0.27 (P<.02). Fasting plasma glucose and plasma glucose area after a 75-g oral glucose tolerance test also were significantly reduced by weight reduction. The change in mean blood pressure after weight reduction was not correlated with the change in body weight or body mass index but was correlated with the reduction in visceral fat area or ratio of visceral fat to subcutaneous fat area. Changes in mean blood pressure also were correlated with changes in fasting plasma glucose levels and the plasma glucose area determined by 75-g oral glucose tolerance test. Results indicate that a decrease in intra-abdominal visceral fat, rather than simply of body weight, may reduce blood pressure in obese hypertensive subjects. The mechanism may involve an improvement in glucose tolerance caused by weight reduction.
Key Words: obesity • hypertension • weight reduction • visceral fat
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Introduction |
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TopAbstractIntroductionMethods Results Discussion References |
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Body weight and blood pressure (BP) have been consistently correlated in several populations.1 2 3 4 5 6 7 8 9 10 11 12 13 14 Short-term weight loss has been shown to substantially reduce BP.15 16 17 18 19 20 21 22 23 24 25 26 27 During the first 2 weeks of a low-calorie diet, there was rapid weight loss and marked natriuresis, together with a significant decrease in BP. A more gradual fall in BP was noted thereafter.17 It is not known why such weight reduction reduces the BP of obese hypertensive subjects and which factors may be most important in this BP fall.
In 1983, we developed a method for estimating fat distribution by means of a computed tomographic (CT) scan.28 We found that the accumulation of intra-abdominal visceral fat is associated with disorders associated with obesity, such as cardiac dysfunction, hypertension, glucose intolerance, and hyperlipidemia. The ratio of the intra-abdominal visceral fat area to the subcutaneous fat area (V/S ratio) at the level of the umbilicus was shown to be a useful and available indication of intra-abdominal visceral fat accumulation.29 30 31 32 33 34 In the present study we investigated the changes in visceral fat accumulation and BP after a 12-week low-calorie diet in obese hypertensive women.
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Methods |
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TopAbstractIntroductionMethods Results Discussion References |
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We evaluated 26 obese hypertensive Japanese women aged 50±13 years (range, 31 to 73) who came to our clinic at The Second Department of Internal Medicine at the Osaka University Hospital for assistance in weight reduction. Men were excluded from study to eliminate the effects of sexual differences.27 35 36 Obese subjects whose body mass index (BMI) was more than 30 kg/m2 were considered for participation. The mean BMI was 33.7±3.1 kg/m2 (30.0 to 38.9). Subjects with systolic BP of 140 mm Hg or higher and/or diastolic BP of 90 mm Hg or higher were defined as hypertensive. All subjects were essential hypertensive individuals with no other circulatory complications. None had received antihypertensive agents. Their body weight had been stable for at least 4 weeks before they consulted our clinic. All subjects gave their informed consent for participation in the study.
Protocol
The subjects' histories were taken at the
initial clinic visit.
A physical examination was conducted, and laboratory tests were
performed. Subjects were instructed to follow a diet that consisted of
1200 kcal/d given as 150 g of carbohydrate, 60 g of protein, 40 g of
fat, and 120 mmol of sodium. They were advised to walk for about an
hour each day if possible. None of them engaged in a program of
vigorous physical exercise. Changes in BP, body weight, topographic
parameters, and hormonal and metabolic
characteristics in plasma and 24-hour urinary sodium excretion were
determined before and after 12 weeks of the low-calorie diet. BP
measurements were taken from the right arm with a mercury manometer
after the subject had briefly rested in a sitting position. Cuff size
was based on girth and length of the upper arm.37 38
Diastolic BP was recorded when the Korotkoff sounds
disappeared (phase V). The mean of three BP measurements was used for
analysis. Mean BP was calculated as two thirds
diastolic BP plus one third systolic BP.
Anthropometric measurements included manual measurements of height to
the nearest 0.1 cm and weight to the nearest 0.1 kg. The circumferences
of the waist and hips were measured to the nearest 0.1 cm at the level
of the umbilicus and the widest circumference over the great
trochanters, respectively, and were used for calculation of the
waist-to-hip circumference ratio. The distribution of body fat
was determined by CT scan according to the procedure of Tokunaga et
al,28 by which the total cross-sectional area,
subcutaneous fat area, and intra-abdominal visceral fat area were
measured at the level of the umbilicus. All CT scans were performed
with the subjects supine with the use of a CT/T scanner (General
Electric Co), and the V/S ratio was calculated. The V/S ratio was
adopted as an index of the relative increase in visceral fat, as
previously reported by our
group.29 30 31 32 33 34
The V/S ratio at
the level of the fourth lumbar vertebra or iliac crests is adopted by
some
investigators35 39 40 41 ;
however, such levels are close
to the umbilicus in most patients. Blood was drawn after an overnight
fast. The blood samples for plasma renin activity,
aldosterone, epinephrine, and
norepinephrine assays were collected in cold tubes
containing disodium EDTA (1.5 mg/mL) and stored at -80°C. Plasma
renin activity and aldosterone concentration were
determined by radioimmunoassay. Plasma epinephrine and
norepinephrine were assayed by high-performance
liquid chromatography. A 75-g oral glucose tolerance
test also was performed. Blood samples were collected at 0, 30, 60, 90,
120, and 180 minutes for determination of plasma glucose and insulin
levels. Plasma glucose was assayed by a glucose oxidase method, and
plasma insulin was assayed by double-antibody radioimmunoassay. The
plasma glucose area and insulin area were determined by calculating the
area under the concentration curve, ie, by multiplying the 30 minutes
by the sum of one half the fasting level; the levels at 30, 60, 90, and
180 minutes; and 1.5 times the level at 120 minutes. Urinary sodium
excretion was also estimated by urine volume for 24 hours. Sodium
concentration was measured by the ion electrode method.
Statistics
Results are expressed as mean±SD. The
significance of
differences between the means of two groups was determined by a paired
t test. Linear regression analysis was used to study
the relationship between the variances. A level of P<.05
was accepted as statistically significant.
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Results |
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TopAbstractIntroductionMethods Results Discussion References |
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Before the study was started, we observed that the relationships between the V/S ratio and systolic (r=.58, P<.01), diastolic (r=.41, P<.05), or mean (r=.54, P<.01) BP were significantly correlated, as shown in Fig 1
.
Changes in anthropometric parameters after the 12-week
1200-kcal diet are shown in Table 1. The subjects lost a
mean of 9.4±4.1 (range, 5.5 to 16.0) kg. The weight loss was
unexpectedly small in some subjects because of their failure to adhere
to the diet. As expected, systolic and diastolic
BPs were significantly reduced by weight reduction. The waist
circumference, hip circumference, and waist-to-hip ratio were
all reduced slightly but significantly. The visceral fat area,
subcutaneous fat area, and V/S ratio at the level of the umbilicus were
also significantly reduced. Changes in plasma hormonal levels, glucose
metabolism, and sodium excretion are shown in Table 2. Plasma
aldosterone and
norepinephrine levels were significantly reduced after
weight reduction. Fasting plasma glucose levels, insulin levels, and
plasma glucose area were also significantly reduced. There were no
significant changes in plasma renin activity, epinephrine, and
mean plasma insulin area, although they were markedly decreased in some
cases. Sodium excretion was also significantly reduced after weight
reduction.
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The relationships between the change in mean BP and some
parameters that were significantly changed after weight
reduction are shown in Table 3. Changes in BP are
represented by the mean BP for simplicity. The changes in
both visceral fat area and V/S ratio were significantly correlated with
changes in mean BP. However, the changes in weight, BMI,
waist-to-hip ratio, and subcutaneous fat area were not
correlated with the changes in mean BP. The changes in the V/S ratio
were not correlated with the changes in body weight (r=.22,
P=NS), BMI (r=.31, P=NS), and
waist-to-hip ratio (r=.10, P=NS). The
changes in fasting plasma glucose and plasma glucose area were also
significantly correlated with the changes in mean BP. Any other changes
in endocrinologic and metabolic characteristics evaluated
in this study were not correlated. A scatterplot between the changes in
V/S ratio and mean BP that showed the most significant correlation in
Table 3 is depicted in Fig 2. Finally, the CT
scans at
the level of the umbilicus of two representative
subjects are shown in Fig 3. The subjects of case 1 and
case 2 lost 10.0 and 12.0 kg during the study, respectively.
Interestingly, the V/S ratio in case 1 was lowered considerably, and
that in case 2 was unaltered even after weight reduction. Furthermore,
a significant fall in BP was observed only in case 1.
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Discussion |
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TopAbstractIntroductionMethods Results Discussion References |
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In the present study, which dealt with severely obese subjects, we found that the V/S ratio and systolic, diastolic, or mean BP were closely correlated before the study was started. This result was consistent with our previous report.34 Moreover, changes in the V/S ratio were closely correlated with changes in BP rather than with those in body weight or other topographic parameters. These data suggest that an increase in visceral fat relative to subcutaneous fat may be involved in the pathogenesis of hypertension in obese subjects. Concerning the changes in endocrinologic or metabolic factors in our study, many such factors were significantly reduced by weight reduction, as has been previously reported.15 16 17 18 19 20 21 22 23 24 25 26 27 However, the changes in fasting plasma glucose and plasma glucose area after a 75-g oral glucose tolerance test were significantly correlated with the changes in mean BP. The changes in V/S ratio were also correlated with the changes in fasting plasma glucose (r=.42, P<.05) and plasma glucose area (r=.51, P<.01) (data not shown). These findings indicate that a relative decrease in visceral fat may be involved in the reduction of BP via an improvement in glucose tolerance.6 8 9 10 11 13 24 42 Generally speaking, an improvement in glucose tolerance must reflect a lessening of insulin resistance. Accordingly, insulin resistance may be important in the pathogenesis of hypertension in obese subjects,43 44 as reported for patients with essential hypertension.45
Why didn't insulin secretion fall significantly after weight reduction in our study? Obese Japanese subjects do not necessarily have hyperinsulinemia even though they have severe insulin resistance, even if they do not have diabetes mellitus. Insulin secretion is thought to be exhausted in such cases. Fortunately, however, most of the subjects recovered insulin secretion by weight reduction. Consequently, insulin levels in our study didn't show a significant fall by weight reduction. Exactly which factor promoted the decrease in visceral fat and why the change in visceral fat differed among the subjects studied remain to be determined. Factors such as sexual hormones, aging, heredity, dietary content, daily amount of exercise, and other factors may be involved.46 47 Although the dietary content and daily amount of exercise were quite consistent in the present study, the change in V/S ratio varied among subjects. Further investigations are required to clarify the mechanism.
In conclusion, a loss of intra-abdominal visceral fat may induce a fall of BP in obese hypertensive subjects. The mechanism may involve an improvement in glucose intolerance brought about by weight reduction.
Received April 26, 1995; first decision July 24, 1995; accepted August 31, 1995.
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