We are all aware of the alarming trends of the increasing frequency of obesity among our population, particularly in children and adolescents. Much discussion has ensued, yet there is little action. Some cities have tried to impose restrictions of dietary salt and saturated fat, while others have limited calories in a “happy meal” to <600. Others have removed sugar-sweetened beverages and processed foods from school vending machines. Yet the percentage of our population who are overweight or obese continues to increase. How can the American Society of Hypertension (ASH) take a leadership role in implementing some change?
The countervailing influence of obesity on the biomeasures of risk for cardiovascular (CV) disease is a major concern. We are all on a genetically predetermined slope of change of blood pressure (BP), cholesterol, and glucose as we age. The slope of change of these values correlate with the development of vascular disease, and the BP is likely the most important initiating and progression factor for vascular disease progression. This can be modified with behavioral changes and medication. The “one-drug hypertensive patient” seems long gone in our clinical practice. We are now faced with patients who require multiple drugs and who are often resistant to the many therapies that we choose. In large part, this may reflect our greater attention to systolic BP and the recommended lower systolic BP goals for patients with diabetes, heart disease, or kidney disease. But it may also be a reflection of the confounding influence of improper diet and obesity. Additionally, patients who are overweight more often may have obstructive sleep apnea and degenerative joint disease, which may require the use of nonsteroidal antiinflammatory drugs. These factors also contribute to BP elevation. Thus, a vicious cycle ensues, which results in more patients who have resistant hypertension.
The opportunity for ASH to partner with state and governmental agencies, the food and beverage industry, the medical community, and the pharmaceutical industry may help reverse the alarming changes and perceptions about being overweight in our society through education and awareness initiatives comparable to campaigns to avoid cigarette smoking. This is particularly important today, as culturally it is more acceptable to be overweight. Social trends illustrate the fact that many patients gain weight when spending time with friends who are overweight. Thus, it is necessary to develop an educational plan that starts earlier in life to provide healthier choices for families, particularly because this influences lifestyle for children and adolescents.
One of the most important areas is food choices. Several opportunities should be considered. There has been much debate about the relationship of salt and BP and whether universal restriction is appropriate. Few would disagree that, on a population basis, modification of dietary salt would result in lower BP. What may be more of an issue is how best to implement a change in the amount of salt in our diet, given that processed food is the source of 80% to 90% of sodium in our diets. Often increased salt comes with increased calorie consumption. Just as important may be the opportunity to encourage the ingestion of foods that are rich in potassium. Modifying salt intake may be more problematic for many compared with increasing foods rich in potassium. Solid evidence in clinical trials indicates that altering the sodium to potassium ratio in the diet may be a key strategy to alter trends in BP. Moreover, encouraging increased consumption of nuts, fruits, and vegetables, as indicated in Dietary Approaches to Stop Hypertension (DASH) studies, is another key strategy to encourage healthier choices that may influence BP in a positive way.
Sugar-sweetened beverages also contribute substantially to weight gain and thus indirectly contribute to BP elevation. Moreover, there are good clinical trial data to indicate that ingestion of 1 or 2 sugar-sweetened beverages per day results in a measurable and clinically relevant increase in BP.
Obtaining more protein through vegetable sources vs animal sources has also been shown to reduce the risk of incident hypertension in women. Thus, with proper education, one can choose healthier dietary options.
Rather than creating a restrictive environment, one can engage in a program to encourage healthier choices. The benefits of proper diet, coupled with modification of alcohol, regular exercise, and even modest changes in weight, can have profound and clinically relevant results in lowering BP and reducing CV risk. These straight-forward messages, coupled with intelligible labeling of food and beverages, may provide proper perspective for families, children, and adolescents. The tastiness and price advantage of fast food must be overcome with cost-effective strategies to choose healthier foods, which can be appropriately seasoned to compete with the fast food choices.
Patient education materials are limited and often not understandable. Engaging the media to provide public service messaging using airtime and newspaper and magazine advertising is of great importance. Simply publishing position papers is not enough. The medical community may be engaged, but the constant reminders and educational support is missing. The pharmaceutical companies need to be engaged as well. The answer is simply not making appetite suppressants and larger multicombination pills for diabetes and hypertension, it is teaching patients how proper lifestyle changes may have an important influence on their risk for obesity, and consequently CV disease and cancer. An additional benefit is the diminished requirement for medication for hypertension, diabetes, and other medical comorbidities.
Moving forward, ASH needs to take a leadership role in brokering the relationship with the media, government, and state and local agencies to expand public awareness. Moreover, the food and beverage and pharmaceutical industries need to be actively engaged. It is likely that without more educational initiatives, the current trend in obesity will reverse the success we had over the past several decades in reducing the incidence of CV disease.