BAB II ANESTESI UMUM In the name of Allah SWT, the author want to say thanks to God, because only God help I can finished my paper which have a title “THE CORRELATION BETWEEN HIGH BLOOD PRESSURE AND OBESITY FOR CHILDREN AT THE AGE OF 10 IN SOUTH JAKARTA IN 2005” on time and without matter problem. This report made for completed the order of lecture English II in the Faculty of Medicine Trisakti University Jakarta. In this case the author would say a million thanks to my family for their pray and support, to Mrs.Tanti who had given a chance and guide to do this paper, and to all my friends for their help on everything. This paper is study about High Blood Pressure, Obesity, and their correlation. And hopefully this paper can be useful to whoever read. For sure the author need developed critics and suggestions for the author reports in the future can be better. Jakarta, June 2008 Bathari Pradnyaparamitha Author 1
Transcript
BAB II
ANESTESI UMUM
In the name of Allah SWT, the author want to say thanks to God, because only God
help I can finished my paper which have a title “THE CORRELATION BETWEEN HIGH
BLOOD PRESSURE AND OBESITY FOR CHILDREN AT THE AGE OF 10 IN
SOUTH JAKARTA IN 2005” on time and without matter problem.
This report made for completed the order of lecture English II in the Faculty of
Medicine Trisakti University Jakarta.
In this case the author would say a million thanks to my family for their pray and
support, to Mrs.Tanti who had given a chance and guide to do this paper, and to all my
friends for their help on everything.
This paper is study about High Blood Pressure, Obesity, and their correlation. And
hopefully this paper can be useful to whoever read. For sure the author need developed
critics and suggestions for the author reports in the future can be better.
Jakarta, June 2008
Bathari Pradnyaparamitha
Author
1
TABLE OF CONTENTS
Preface …………………………………………………………………………1
Table of Contents ……………………………………………………………...2
Chapter 1 – Introduction
1.1. Background ……………………………………………………….4
1.2. Problem …………………………………………………………...4
1.3. Limitation of Problems …………………………………………...5
1.4. Objectives ………………………………………………………...6
1.5. Methods of Writing ……………………………………………….6
1.6. Frame of Writing …………………………………………………6
Chapter 2 – High Blood Pressure
2.1. Definition …………………………………………………………8
2.2. Etiology …………………………………………………………...9
2.3. Epidemiology …………………………………………………….11
2.4. Histopathology …………………………………………………...12
2.5. Symptomatology …………………………………………………13
2.6. Diagnosis ………………………………………………………...14
2.7. Therapy …………………………………………………………..16
2.8. Treatment ………………………………………………………...17
2.9. Complication ……………………………………………………..18
2.10. Prevention …………………………………………………….19
Chapter 3 – Obesity
3.1. Definition ………………………………………………………..20
3.2. Etiology ………………………………………………………….20
3.3. Epidemiology ……………………………………………………23
3.4. Symptomatology ………………………………………………...23
3.5. Diagnosis ………………………………………………………...24
3.6. Therapy …………………………………………………………..25
3.7. Treatment ………………………………………………………...26
2
3.8. Complication ……………………………………………………..27
3.9. Prevention …………………………………………………….31
Chapter 4 - The Correlation Between High Blood Pressure and Obesity for Children at the
Age of 10 in South Jakarta in 2005
4.1. Cases ………………………………………………………….32
4.2. Pathology ……………………………………………………..32
4.3. Diagnosis ……………………………………………………..34
4.4. Treatment ……………………………………………………..34
Chapter 5- Conclusion …………………………………………………….37
Bibliography ………………………………………………………………38
3
CHAPTER I
INTRODUCTION
1.1 DEFINISI
Anestesi umum adalah tindakan meniadakan nyeri sentral disertai hilangnya
kesadaran yang bersifat reversibel. Dengan anestesi umum akan diperoleh trias
anestesia, yaitu:2
Hipnotik (tidur)
Analgesia (bebas dari nyeri)
Relaksasi otot (mengurangi ketegangan tonus otot)
Hanya eter yang memiliki trias anestesia. Karena anestesi modern saat ini
menggunakan obat-obat selain eter, maka anestesi diperoleh dengan menggabungkan
berbagai macam obat.
1.2 METODE ANESTESI UMUM 2
I. Parenteral
Anestesia umum yang diberikan secara parenteral baik intravena maupun
intramuskular biasanya digunakan untuk tindakan yang singkat atau untuk
induksi anestesia.
II. Perektal
Metode ini sering digunakan pada anak, terutama untuk induksi anestesia
maupun tindakan singkat.
III. Perinhalasi
Yaitu menggunakan gas atau cairan anestetika yang mudah menguap (volatile
agent) dan diberikan dengan O2. Konsentrasi zat anestetika tersebut
tergantunug dari tekanan parsialnya; zat anestetika disebut kuat apabila dengan
tekanan parsial yang rendah sudah mampu memberikan anestesia yang adekuat.
1.3 FAKTOR-FAKTOR YANG MEMPENGARUHI ANESTESI UMUM 2
A. Faktor Respirasi
Hal-hal yang mempengaruhi tekanan parsial zat anestetika dalam alveolus
adalah:
1. Konsentrasi zat anestetika yang diinhalasi; semakin tinggi konsentrasi, semakin
cepat kenaikan tekanan parsial
4
2. Ventilasi alveolus; semakin tinggi ventilasi, semakin cepat kenaikan tekanan
parsial
B. Faktor Sirkulasi
Saat induksi, konsentrasi zat anestetika dalam darah arterial lebih besar
daripada darah vena. Faktor yang mempengaruhinya adalah:
Perubahan tekanan parsial zat anestetika yang jenuh dalam alveolus dan darah
vena. Dalam sirkulasi, sebagian zat anestetika diserap jaringan dan sebagian
kembali melalui vena.
Koefisien partisi darah/gas yaitu rasio konsentrasi zat anestetika dalam darah
terhadap konsentrasi dalam gas setelah keduanya dalam keadaan seimbang.
Aliran darah, yaitu aliran darah paru dan curah jantung.
C. Faktor Jaringan
Perbedaan tekanan parsial obat anestetika antara darah arteri dan jaringan
Koefisien partisi jaringan/darah
Aliran darah dalam masing-masing 4 kelompok jaringan (jaringan kaya
pembuluh darah/JKPD, kelompok intermediate, lemak, dan jaringan sedikit
pembuluh darah/JSPD)
D. Faktor Zat Anestetika
Potensi dari berbagai macam obat anestetika ditentukan oleh MAC
(Minimal Alveolus Concentration), yaitu konsentrasi terendah zat anestetika dalam
udara alveolus yang mampu mencegah terjadinya tanggapan (respon) terhadap
rangsang rasa sakit. Semakin rendah nilai MAC, semakin poten zat anestetika
tersebut.
E. Faktor Lain
Ventilasi, semakin besar ventilasi, semakin cepat pendalaman anestesi
Curah jantung, semakin tinggi curah jantung, semakin lambat induksi dan
pendalaman anestesia
Suhu, semakin turun suhu, semakin larut zat anestesia sehingga pendalaman
anestesia semakin cepat.
1.4 STADIUM ANESTESI UMUM
Obesity is a common problem in much of the western world today in that is linked
directly with several disease processes, notably, hypertension. It is becoming clear that the
adipocyte is not merely an inert organ for storage of energy but that it also secretes a host
5
of factors that interact with each other and may result in elevated blood pressure. Of
particular importance is the putative role of leptin in the causation of hypertension via an
activation of the sympathetic nervous system and a direct effect on the kidneys, resulting in
increased sodium reabsorption leading to hypertension. Obesity per se may have structural
effects on the kidneys that may perpetuate hypertension, leading to an increased incidence
of end-stage renal disease that results in further hypertension. Adipose tissue may elaborate
angiotensin from its own local renin-angiotensin system. The distribution of body fat is
considered important in the genesis of the obesity-hypertension syndrome, with a
predominantly central distribution being particularly ominous. Weight loss is the
cornerstone in the management of the obesity-hypertension syndrome. It may be achieved
with diet, exercise, medications, and a combination of these measures. Anti-obesity
medications that are currently undergoing clinical trials may play a promising role in the
management of obesity and may also result in lowering of blood pressure.
Antihypertensives are considered important components in the holistic approach to the
management of this complex problem.
1.5 Problem
The prevalence of overweight and obesity in Jakarta makes obesity a leading public
health problem. Jakarta has the highest rates of obesity in the Indonesia. From 1980 to
2002, obesity has doubled in adults and overweight prevalence has tripled in children and
adolescents. From 2004-2007, 32.2% of adults aged 20 years or older were obese. The
prevalence in the Jakarta continues to rise. The prevalence of obesity has been continually
rising for two decades. This sudden rise in obesity prevalence is attributed to
environmental and population factors rather than individual behavior and biology because
of the rapid and continual rise in the number of overweight and obese individuals. The
current environment produces risk factors for decreased physical activity and for increased
calorie consumption. These environmental factors operate on the population to decrease
physical activity and increase calorie consumption.
Since most developed countries have an ageing population, the prevalence of
hypertension is increasing. This age-driven increase in cardiovascular risk is an important
factor contributing to the increasing burden of mortality and morbidity associated with
cardiovascular disease. Today, there is a strong rationale for an aggressive approach to
6
hypertension since antihypertensive treatment has been shown to reduce cardiovascular
mortality and morbidity in the elderly. It is likely that increasing emphasis will be placed
on control of isolated and borderline systolic hypertension, which are the predominant
forms of hypertension in elderly patients. The recent second Swedish Trial in Old Patients
with Hypertension (STOP-Hypertension-2) represents an important contribution to the
literature since it shows that newer antihypertensive agents, such as angiotensin converting
enzyme (ACE) inhibitors and calcium antagonists, are as effective as older agents in
reducing cardiovascular mortality and morbidity in elderly patients.
1.6 Limitation of Problems
What is high blood pressure ?
What are the signs and symptoms of high blood pressure ?
What causes high blood pressure?
What are the risk factors of high blood pressure?
How to diagnose high blood pressure?
What are complications of high blood pressure?
How are high blood pressure treated ?
How to prevent high blood pressure?
What are over obesity ?
What causes obesity ?
What are the health risks of obesity ?
What are the signs and symptoms of obesity ?
How are obesity diagnosed ?
How are obesity treated ?
How can obesity be prevented ?
1.7 Objective
To explain about high blood pressure
To give information about the causes of high blood pressure
To give information about the signs, symptoms and diagnosis of high blood
pressure
To give information about the complications of high blood pressure
7
To give information about the treatment for high blood pressure
To give information about obesity
To give information about the causes of obesity
To explain about the health risks of obesity
To give information about the signs, symptoms and diagnosis of obesity
To give information about the treatments for obesity
1.8 Methods of Writing
I get the information and data from some books to complete this paper.
Beside that, I get the other information for my paper from some websites on the
internet.
1.9 Frame of Writing
PREFACE
CONTENTS
CHAPTER 1 – INTRODUCTION
1.1 Background
1.2 Problems
1.3 Limitation of problems
1.4 Objectives
1.5 Method of writing
1.6 Frame of writing
CHAPTER 2 – HIGH BLOOD PRESSURE
2.1 Definition
2.2 Etiology
2.3 Epidemiology
2.4 Histopathology
2.5 Symptomatology
2.6 Diagnosis
2.7 Therapy
2.8 Treatment
2.9. Complication
8
2.10. Prevention
CHAPTER 3 – OBESITY
3.1 Definition
3.2 Etiology
3.3. Epidemiology
3.4 Symtomatology
3.5. Diagnosis
3.6. Therapy
3.7. Treatment
3.8. Complication
3.9. Prevention
CHAPTER 4 – THE CORRELATION BETWEEN HIGH BLOOD PRESSURE AND
OBESITY FOR CHILDREN AT THE AGE OF 10 IN SOUTH JAKARTA IN 2005
4.1. Cases
4.2. Pathology
4.3. Diagnosis
4.4. Treatment
CHAPTER 5 – CONCLUSION
BIBLIOGRAPHY
CHAPTER 2
HIGH BLOOD PRESSURE
2.1. Definition
High blood pressure (hbp) or hypertension means high pressure (tension) in the
arteries. Arteries are vessels that carry blood from the pumping heart to all the tissues and
organs of the body. High blood pressure does not mean excessive emotional tension,
although emotional tension and stress can temporarily increase blood pressure. Normal
blood pressure is below 120/80; blood pressure between 120/80 and 139/89 is called "pre-
hypertension", and a blood pressure of 140/90 or above is considered high.
9
The top number, the systolic blood pressure, corresponds to the pressure in the
arteries as the heart contracts and pumps blood forward into the arteries. The bottom
number, the diastolic pressure, represents the pressure in the arteries as the heart relaxes
after the contraction. The diastolic pressure reflects the lowest pressure to which the
arteries are exposed.
An elevation of the systolic and/or diastolic blood pressure increases the risk of
developing heart (cardiac) disease, kidney (renal) disease, hardening of the arteries
(atherosclerosis or arteriosclerosis), eye damage, and stroke (brain damage). These
complications of hypertension are often referred to as end-organ damage because damage
to these organs is the end result of chronic (long duration) high blood pressure. For that
reason, the diagnosis of high blood pressure is important so efforts can be made to
normalize blood pressure and prevent complications.
Hypertension is classified as either primary (or essential) hypertension or secondary
hypertension. Primary hypertension has no specific origin but is strongly associated with
lifestyle. It is responsible for 90 to 95 percent of diagnosed hypertension and is treated with
stress management, changes in diet, increased physical activity, and medication (if
needed). Secondary hypertension is responsible for 5 to 10 percent of diagnosed
hypertension. It is caused by a preexisting medical condition such as congestive heart
failure, kidney failure, liver failure, or damage to the endocrine (hormone) system.
Pregnancy-induced hypertension (PIH) may appear in otherwise healthy women
after the twentieth week of pregnancy. It is more likely to occur in women who are
overweight or obese. PIH may be mild or severe, and it is accompanied by water retention
and protein in the urine. About 5 percent of PIH cases progress to preeclampsia.
Preeclampsia is characterized by dizziness, headache, visual disturbance, abdominal pain,
facial edema, poor appetite, nausea, and vomiting. Severe preeclampsia affects the
mother's blood system, kidneys, brain, and other organs. In rare cases, the woman can die.
Preeclampsia is more likely to occur during first pregnancies, multiple fetuses, in women
with existing hypertension, and in women younger than twenty-five years old or over
thirty-five years old. If convulsions occur with PIH, it is called eclampsia. PIH disappears
within a few weeks after birth
10
2.2 Etiology
The causes of high blood pressure are complex. Obesity has long been recognised
to be a major determinant of blood pressure. Obesity is largely determined by an
interaction between diet (calorie intake) and exercise (calorie consumption). Diet also has
direct effects on blood pressure, largely mediated through Na+ intake. Exercise may have
direct effects on blood pressure. There is evidence from primate studies that social status
affects blood pressure through its link to chronic stress exposure. Two forms of high blood
pressure have been described: essential (or primary) hypertension and secondary
hypertension. Essential hypertension is a far more common condition and accounts for
95% of hypertension. The cause of essential hypertension is multifactorial, that is, there are
several factors whose combined effects produce hypertension. In secondary hypertension,
which accounts for 5% of hypertension, the high blood pressure is secondary to (caused
by) a specific abnormality in one of the organs or systems of the body.
Genetic factors are thought to play a prominent role in the development of essential
hypertension. However, the genes for hypertension have not yet been identified. (Genes are
tiny portions of chromosomes that produce the proteins that determine the characteristics
of individuals.) The current research in this area is focused on the genetic factors that affect
the renin-angiotensin-aldosterone system. This system helps to regulate blood pressure by
controlling salt balance and the tone (state of elasticity) of the arteries. Rarely, certain
unusual genetic disorders affecting the hormones of the adrenal glands may lead to
hypertension. (These identified genetic disorders are actually considered secondary
hypertension.)
The vast majority of patients with essential hypertension have in common a
particular abnormality of the arteries: an increased resistance (stiffness or lack of elasticity)
in the tiny arteries that are most distant from the heart (peripheral arteries or arterioles).
The arterioles supply oxygen-containing blood and nutrients to all of the tissues of the
body. The arterioles are connected by capillaries in the tissues to the veins (the venous
system), which returns the blood to the heart and lungs. Just what makes the peripheral
arteries become stiff is not known. Yet, this increased peripheral arteriolar stiffness is
present in those individuals whose essential hypertension is associated with genetic factors,
obesity, lack of exercise, overuse of salt, and aging. Inflammation also may play a role in
hypertension since a predictor of the development of hypertension is the presence of an
11
elevated C reactive protein level (a blood test marker of inflammation) in some individuals.
Risk factors for hypertension include:
- age over 60
- male sex
- race
- heredity
- salt sensitivity
- obesity
- inactive lifestyle
- heavy alcohol consumption
- use of oral contraceptives
2.3. Epidemiology
The prevalence of hypertension differs among racial and ethnic groups compared
with the general population. For example, American Indians have the same prevalence as,
or a higher prevalence than, the general population; among Hispanics, blood pressure is
generally the same as or lower than that of non-Hispanic whites, despite a high prevalence
of obesity and type 2 diabetes mellitus. It also appears that South Asians are more
responsive to various antihypertensive medications than whites. Evidence shows that
hypertension awareness, treatment, and control in some groups, especially those with
generally lower socioeconomic status, require more focused hypertension education and
intervention programs.
The prevalence of hypertension in African Americans is among the highest in the
world. Compared with whites, hypertension develops earlier in life and average blood
pressures are much higher in African Americans. African Americans have higher rates of
stage 3 hypertension than whites, causing a greater burden of hypertension complications.
12
This earlier onset, higher prevalence, and greater rate of stage 3 hypertension in African
Americans is accompanied by an 80-percent higher stroke mortality rate, a 50-percent
higher heart disease mortality rate, and a 320-percent greater rate of hypertension-related
end-stage renal disease than seen in the general population.
A new study on risk factors in cardiovascular disease in Asia has found that blood
pressure is more strongly related to coronary heart disease and stroke in Asia, as compared
with Western countries such as Australia and New Zealand.
A paper from the George Institute for International Health on the outcomes of the
study, to be published in the October 2005 issue of the European Journal of Cardiovascular
Prevention and Rehabilitation, notes that high blood pressure is a key risk factor for
haemorrhagic stroke, which is relatively more common amongst Asian populations. A
10mmHg increase in systolic blood pressure was found to be associated with a 72% greater
risk of having a haemorrhagic stroke in Asian groups, compared with 49% in Australia and
New Zealand.
Recent data suggest that hypertension (high blood pressure) is higher in many
Asian countries than in Australia. For example, around 28% of people in China are
estimated to have hypertension, compared with 19% in Australia. In India and Japan, the
percentages are higher still.
2.4. Histopathology
The pulmonary arteries in pulmonary arterial hypertension (PAH) are characterized
by medial hypertrophy and muscularization, intimal fibrosis, adventitial proliferation and
obliteration of small arteries. The medial hypertrophy is also the most commonly identified
lesion in pulmonary hypertension (PHT), and not restricted to PHT of any etiology, also is
considered to be the precursor to subsequent vascular alterations. Several types of intimal
lesions form part of the continuum of changes associated with plexogenic pulmonary
arteriopathy, although this lesion is found in many cases with primary pulmonary arterial
hypertension (PPH), are not pathognomonic, because they are also found in cases of severe
pulmonary hypertension associated with other diseases.
The genetics basis of familial PPH is unknown, but the clinical and pathological
features are the same as in sporadically occurring PPH; this form displays genetic
13
anticipation and an abnormal gender ratio at birth. This phenomenon, genetic anticipation,
suggests that the molecular basis of familial PPH may be trinucleotide-repeat expansion,
which is linked to unidentified genes of chromosome 2; but others investigators have
reported an association between the major histocompatibility complex and PPH. The
patients with this disease suggest that the coagulation system on the endothelial surface
may be activated as either a primary or a secondary process.
Vasoconstriction is a variable feature of PHT. Thromboxane A2 is both a potent
pulmonary vasoconstrictor and a procoagulant whereas prostacyclin has opposing effects,
and an imbalance between the releases of these two mediators could be involved in the
pathogenesis of the arteriopathy. Since the endothe lium produce an excessive production
of vasoconstrictors relative to vasodilators, and the smooth muscle cells are depolarized
and calcium-overloaded, which is due in part to reduced expression of voltage-gated
potassium channels (Kv). This causes vasoconstriction and may promote cell proliferation.
Even abnormal matrix metalloproteinase and elastase activity could also explain the
abnormal vascular tone, platelet activation, and remodeling in PPH.
2.5. Symptomatology
Hypertension is a major health problem, especially because it has no obvious
symptoms. Many people have hypertension without showing any obvious symptoms.
People with high blood pressure often do not feel sick. In fact, hypertension is often called
"the silent killer" because it may cause no symptoms at all for a long time. Your organs
and tissues can be damaged by hypertension without you knowing or feeling any 'external'
symptoms.
Most people with primary hypertension don't have any obvious symptoms at all,
also the possible symptoms of hypertension vary quite a lot from person to person. These
symptoms could also be symptoms of other health problems, however here are a few of the
more common symptoms of hypertension to look out for.
1. Chronic headaches
2. Dizziness or Vertigo
3. Blurry or double vision.
4. Drowsiness
14
5. Nausea
6. Shortness of breath
7. Heart palpitations
8. Fatigue - general tiredness
9. A flushed face
10. Nosebleeds
11. A strong need to urinate often (especially during the night)
12. Tinnitus (a ringing or buzzing in the ears)
13. Chest pain or pressure
14. Dizzy spells and fainting
15. Ankle or leg swelling (edema)
16. Bloating
2.6. Diagnosis
Because hypertension doesn't cause symptoms, it is important to have blood
pressure checked regularly. Blood pressure is measured with an instrument called a
sphygmomanometer. A cloth-covered rubber cuff is wrapped around the upper arm and
inflated. When the cuff is inflated, an artery in the arm is squeezed to momentarily stop the
flow of blood. Then, the air is let out of the cuff while a stethoscope placed over the artery
is used to detect the sound of the blood spurting back through the artery. This first sound is
the systolic pressure, the pressure when the heart beats. The last sound heard as the rest of
the air is released is the diastolic pressure, the pressure between heart beats. Both sounds
are recorded on the mercury gauge on the sphygmomanometer.
Normal blood pressure is defined by a range of values. Blood pressure lower than
120/80 mm Hg is considered normal. A number of factors such as pain, stress or anxiety
can cause a temporary increase in blood pressure. For this reason, hypertension is not
diagnosed on one high blood pressure reading. If a blood pressure reading is 120/80 or
higher for the first time, the physician will have the person return for another blood
pressure check. Diagnosis of hypertension usually is made based on two or more readings
15
after the first visit.
Systolic hypertension of the elderly is common and is diagnosed when the diastolic
pressure is normal or low, but the systolic is elevated, e.g.170/70 mm Hg. This condition
usually co-exists with hardening of the arteries (atherosclerosis).
Blood pressure measurements are classified in stages, according to severity:
- normal blood pressure: less than less than 120/80 mm Hg
- pre-hypertension: 120-129/80-89 mm Hg
- Stage 1 hypertension: 140-159/90-99 mm Hg
- Stage 2 hypertension: at or greater than 160-179/100-109 mm Hg
A typical physical examination to evaluate hypertension includes:
- medical and family history
- physical examination
- ophthalmoscopy: Examination of the blood vessels in the eye
- chest x ray
- electrocardiograph (ECG)
- blood and urine tests.
The medical and family history help the physician determine if the patient has any
conditions or disorders that might contribute to or cause the hypertension. A family history
of hypertension might suggest a genetic predisposition for hypertension.
The physical exam may include several blood pressure readings at different times
and in different positions. The physician uses a stethoscope to listen to sounds made by the
heart and blood flowing through the arteries. The pulse, reflexes, and height and weight are
checked and recorded. Internal organs are palpated, or felt, to determine if they are
enlarged.
Because hypertension can cause damage to the blood vessels in the eyes, the eyes
16
may be checked with a instrument called an ophthalmoscope. The physician will look for
thickening, narrowing, or hemorrhages in the blood vessels. A chest x ray can detect an
enlarged heart, other vascular (heart) abnormalities, or lung disease. An electrocardiogram
(ECG) measures the electrical activity of the heart. It can detect if the heart muscle is
enlarged and if there is damage to the heart muscle from blocked arteries. Urine and blood
tests may be done to evaluate health and to detect the presence of disorders that might
cause hypertension.
2.7. Therapy
There is no cure for primary hypertension, but blood pressure can almost always be
lowered with the correct treatment. The goal of treatment is to lower blood pressure to
levels that will prevent heart disease and other complications of hypertension. In secondary
hypertension, the disease that is responsible for the hypertension is treated in addition to
the hypertension itself. Successful treatment of the underlying disorder may cure the
secondary hypertension.
Patients whose blood pressure falls into the Stage 1 hypertension range may be
advised to take antihypertensive medication. Numerous drugs have been developed to treat
hypertension. The choice of medication will depend on the stage of hypertension, side
effects, other medical conditions the patient may have, and other medicines the patient is
taking.
Treatment with a single medicine fails to lower blood pressure enough, a different
medicine may be tried or another medicine may be added to the first. Patients with more
severe hypertension may initially be given a combination of medicines to control their
hypertension. Combining antihypertensive medicines with different types of action often
controls blood pressure with smaller doses of each drug than would be needed for just one.
Diuretics help the kidneys eliminate excess salt and water from the body's tissues
and the blood. This helps reduce the swelling caused by fluid buildup in the tissues. The
reduction of fluid dilates the walls of arteries and lowers blood pressure. New guidelines
released in 2003 suggest diuretics as the first drug of choice for most patients with high
blood pressure and as part of any multi-drug combination.
17
Beta-blockers lower blood pressure by acting on the nervous system to slow the
heart rate and reduce the force of the heart's contraction. They are used with caution in
patients with heart failure, asthma, diabetes, or circulation problems in the hands and feet.
Calcium channel blockers block the entry of calcium into muscle cells in artery
walls. Muscle cells need calcium to constrict, so reducing their calcium keeps them more
relaxed and lowers blood pressure.
ACE inhibitors block the production of substances that constrict blood vessels.
They also help reduce the build-up of water and salt in the tissues. They often are given to
patients with heart failure, kidney disease, or diabetes. ACE inhibitors may be used
together with diuretics.
Alpha-blockers act on the nervous system to dilate arteries and reduce the force of
the heart's contractions. Alpha-beta blockers combine the actions of alpha and beta
blockers. Vasodilators act directly on arteries to relax their walls so blood can move more
easily through them. They lower blood pressure rapidly and are injected in hypertensive
emergencies when patients have dangerously high blood pressure.
Peripheral acting adrenergic antagonists act on the nervous system to relax
arteries and reduce the force of the heart's contractions. They usually are prescribed
together with a diuretic. Peripheral acting adrenergic antagonists can cause slowed mental
function and lethargy. Centrally acting agonists also act on the nervous system to relax
arteries and slow the heart rate. They are usually used with other antihypertensive
medicines.
2.8. Treatment
Actual combinations of medications and lifestyle changes will vary from one
person to the next. Treatment to lower blood pressure may include changes in diet, getting
regular exercise, and taking antihypertensive medications. Patients falling into the pre-
hypertension range who don't have damage to the heart or kidneys often are advised to
make needed lifestyle changes only.
Lifestyle changes that may reduce blood pressure by about 5 to 10 mm Hg include:
18
- reducing salt intake
- reducing fat intake
- losing weight
- getting regular exercise
- quitting smoking
- reducing alcohol consumption
- managing stress
2.9. Complication
Excessive pressure on the artery walls can damage your vital organs. The higher
your blood pressure and the longer it goes uncontrolled, the greater the damage.
Uncontrolled high blood pressure can lead to:
1. Damage to your arteries. This can result in hardening and thickening of the
arteries (atherosclerosis), which can lead to a heart attack or other complications.
An enlarged, bulging blood vessel (aneurysm) also is possible.
2. Heart failure. To pump blood against the higher pressure in your vessels, your
heart muscle thickens. Eventually, the thickened muscle may have a hard time
pumping enough blood to meet your body's needs, which can lead to heart failure.
3. A blocked or ruptured blood vessel in your brain. This can lead to stroke.
4. Weakened and narrowed blood vessels in your kidneys. This can prevent these
organs from functioning normally.
5. Thickened, narrowed or torn blood vessels in the eyes. This can result in vision
loss.
6. Metabolic syndrome. This syndrome is a cluster of disorders of your body's
19
metabolism — including elevated waist circumference, high triglycerides, low
high-density lipoprotein (HDL), or "good," cholesterol, high blood pressure and
high insulin levels. If you have high blood pressure, you're more likely to have
other components of metabolic syndrome. The more components you have, the
greater your risk of developing diabetes, heart disease or stroke.
Uncontrolled high blood pressure also may affect your ability to think, remember and
learn. Cognitive impairment and dementia are more common in people who have high
blood pressure.
2.10. Prevention
Prevention of hypertension centers on avoiding or eliminating known risk factors.
Even persons at risk because of age, race, or sex or those who have an inherited risk can
lower their chance of developing hypertension.
The risk of developing hypertension can be reduced by making the same changes
recommended for treating hypertension:
- reducing salt intake
- reducing fat intake
- losing weight
- getting regular exercise
- quitting smoking
- reducing alcohol consumption
- managing stress
20
CHAPTER III
OBESITY
3.1. Definition
Obesity is an excess of body fat that frequently results in a significant
impairment of health. Obesity results when the size or number of fat cells in a person's
body increases. A normal-sized person has between 30 and 35 billion fat cells. When a
person gains weight, these fat cells first increase in size and later in number. One pound of
body fat represents about 3500 calories.
Obesity is a condition in which the natural energy reserve, stored in the fatty
tissue of humans and other mammals, exceeds healthy limits. It is commonly defined as a
body mass index (weight divided by height squared) of 30 kg/m2 or higher. Obesity is an
abnormal accumulation of body fat, usually 20 percent or more over an individual's ideal
body weight. Obesity is associated with an increased risk of illness, disability, and death.
3.2. Etiology
Obesity results when there is an imbalance between energy intake and energy
expenditure. In other words, you consume more calories than you expend in your daily
activities. Weight gained during certain critical periods of your life more commonly lead to
an increased number (as opposed to increased size) of fat cells and make obesity more
difficult to treat. These time periods are:
1. Between 12 and 18 months of age.
2. Between 12 and 16 years of age.
3. Adulthood when a person gains in excess of 60% of their ideal body weight.
21
4. Pregnancy.
During these periods, an excessive amount of weight gain causes an increased
number of fat cells. Once a fat cell is formed, you generally cannot get rid of it. However,
recent studies imply that use of certain medications can destroy fat cells and that a decrease
in the number of fat cells can occur if you maintain a lower body weight for a prolonged
period of time.
There are differences in people, and several factors that contribute to these
differences have been identified:
1. Age
As a general rule, as you grow older, your metabolic rate slows down and you
do not require as many calories to maintain your weight. People frequently state that they
eat the same and do the same activities as they did when they were 20 years old, but at 40,
are gaining weight. This will happen. Metabolism slows down with advancing age.
2. Gender
Gender is also an important factor. Males have a higher resting metabolic rate
than females, so males require more calories to maintain their body weight. This higher
resting metabolic rate is primarily due to the increased lean body mass (mainly muscle
tissue) males have compared to women. Additionally, when women enter menopause, their
metabolic rates decrease significantly. That is part of the reason why many women start
gaining weight after menopause.
3. Activity level
Active individuals require more calories than less active ones. Physical activity
tends to diminish appetite in obese individuals while increasing the body's ability to
preferentially metabolize fat as an energy source. It is believed that much of the increase in
obesity in the last 25 years has resulted from the decreased level of physical activity in
everyday life (such as emailing coworkers instead of walking over to their desks.
22
4. Body weight
Heavier people require more calories to maintain their body weights than
lighter ones. For example, a middle-aged male weighting 250 lbs. doing minimal amounts
of physical activity may require 2700 calories to maintain his body weight. If this person
goes on a 2000 calorie-per-day diet, he will lose weight. Eventually, however, even if he
stays with a 2000-calorie daily diet, his weight will stabilize because his metabolic rate
will gradually decrease. When this man reaches approximately 200 lbs., he will require
perhaps only about 2000 calories per day to maintain his new weight. This is a normal
process and takes place in all individuals.
5. Food preferences
High fat foods are obesity-promoting in animals and humans. In the last 25
years, the ready availability of high fat foods (such as, "fast foods"), combined with the
decreased calorie requirements from decreased physical activity, is felt to be the major
factor in the sharp rise in the prevalence of obesity. Thus, the current low carb, high fat diet
craze, which encourages intake of fatty meats instead of vegetables ("carbs"), will, in the
long run, result in an even a sharper rise in obesity and probably heart disease, as well.
6. Medications
Certain medications prescribed for inflammatory conditions, seizures, and
mental illness tend to increase appetite and may also decrease metabolic rate.
7. Hereditary factors affecting appetite and metabolism
Heredity is associated not only with obesity, but also with thinness. It most
closely correlates with the biological mother's weight. If the biological mother is heavy as
an adult, there is approximately a 75% chance that her children will be heavy. If the
biological mother is thin, there is also a 75% chance that her children will be thin. It is
related to metabolic processes inherited primarily from the biological mother. These
differences are independent of thyroid activity which, incidentally, is a relatively rare cause
of obesity.
23
3.3. Epidemiology
According to the Centers for Disease Control and Prevention (CDC)
Behavioral Risk Factor Surveillance System (BRFSS), self-reported prevalence of obesity
among US adults increased from 12% in 1991 to 18% in 1998. [8] Data from the 1988 to
1994 National Health and Nutrition Examination Survey (NHANES) suggested that 63%
of men and 55% of women were overweight. [9] More recent (1999) data from NHANES
IV found that obesity rates among adult Americans increased from 15% in 1980 to 27% in
1999. [10]
The magnitude of the increased prevalence of obesity in the US between
1991 and 1998 varies by region. It ranges from 31.9% in the mid-Atlantic to 67.2% in the
south Atlantic regions. [8] The increased prevalence also varies considerably by state
ranging from 11.3% in Delaware to 101.8% for Georgia. [8] In another survey, Missouri
ranked 2nd in overweight. [11] The magnitude of the increase is greatest in 18 to 29 year
olds (7.1% to 12.1%), those with some college education (10.6% to 17.8%), and those of
Hispanic ethnicity (11.6% to 20.8%). [8]
3.4. Symptomatology
The following are the most common symptoms that indicate a person is
obese. However, each person may experience symptoms differently. Symptoms may
include:
facial features often appear disproportionate
adiposity (fat cells) in the breast region in boys
large abdomen (white or purple marks are sometimes present)
in males, external genitals may appear disproportionately small
puberty may occur early
increased adiposity in the upper arms and thighs
genu valgum (knock kneed) is common
Arthritis (see arthritis entry) and other problems with bones and muscles, such as
lower back pain
Heartburn
24
High cholesterol levels
High blood pressure
Menstrual problems
Shortness of breath
Skin disorders
People who are obese often experience significant social pressure, stress,
and difficulties accomplishing developmental tasks. Psychologic disturbances are also very
common. The symptoms of obesity may resemble other conditions or medical problems.
3.5. Diagnosis
Tests to diagnose obesity include:
1. Body Mass Index (BMI) – Calculated by dividing your weight in kilograms by your height in meters squared. A BMI of 25 to 29.9 is considered overweight and 30 or higher is considered obese. (Source: Centers for Disease Control and Prevention and National Heart, Lung, and Blood Institute)
Classification of
ObesityBMI
Obesity
Class
Disease Risk (Relative to Normal Weight and Waist
Circumference)
Men < 40 in (102 cm)
Women < 35 in (88 cm)
Men > 40 in
Women > 35 in
Underweight<18.
5
Normal18.5-
24.9
Overweight25.0-
29.9Increased High
Obesity30.0-
34.9I High Very High
25
Obesity35.0-
39.9II Very High Very High
Extreme Obesity > 40 III Extremely High Extremely High
2. Waist Circumference, Saggital Diameter, and Waist-To-Hip Ratio – Simple
measurements that estimate the amount of fat deposited in the skin and inside the abdominal cavity. Waist circumferences that exceed 102 centimeters (40 inches) in men and 88 centimeters (35 inches) in women are associated with an increased risk of heart disease.
3. Skinfold Caliper – Most fat is deposited beneath the skin. This test measures fat just beneath the skin, but cannot measure fat accumulated inside the abdomen.
4. Water Displacement Tests – Fat floats; the rest of your body tissues sink. Determining how well you float provides an estimated ratio of fat to body mass.
5. Electrical Measurements – A couple of tests calculate your percentage of body fat by measuring the difference between the electrical characteristics of fat and other tissues in your body.
6. Blood tests – To rule out other medical conditions that may cause excess body weight,
such as a thyroid disorder, your doctor may order some blood tests
3.6. Therapy
Besides drugs and surgery, several fat binding products are available in the
market for weight loss. Proactol is a clinically proven weight loss product, now available
in the market. Proactol is highly recommended as the most effective therapy for obesity
because of its proven advantages and benefits.
The advantage of Proactol over other products is that it is the first weight
loss device product that is approved as a Medical Device Product (MDD 93/42/EEC). It
can come under the regulation medical device because it changes the mechanical process
of digesting food in the body. Proactol is safe, clinically proven and result oriented to
reduce fat.
Proactol meets the strict guidelines put forward by the Medicines and
Healthcare products Regulatory Agency (MHRA), USA. It is also the first ‘green’ weight
26
loss product that is free from allergens, artificial coloring, flavors, salt, gluten and
preservatives, certified by UK’s Vegetarian Society and certified organic by EcoCert.
Another major factor why we recommend Proactol for obesity therapy is
because it is clinically proven to bind more than 27 per cent fat intake and also reduce
calorie generated from the food consumed. It, however, retains the necessary nutrition
needed for a body. It also works as an appetite suppressant and thereby reduces cravings
for food. And the best part is there are no reported side effects. All of these claims are
backed by at least four published clinical studies.
3.7. Treatment
There are many treatment options for people who are suffering from
obesity. The best treatment is for an obese individual to decrease their calorie intake, to
decrease their fat consumption, to only use clinically proven obesity treatment product, to
become more active and to participate in physical manual labor. All of these factors form a
winning therapy in order to fight obesity. Many people will try weight loss pills, whether
prescribed or herbal, but they only work in conjunction with a healthy diet and vigorous
exercise program. People using these pills should be reminded of their serious side effects.
Obese people also have the choice to have surgery performed but this option is usually
only used in severe cases.
Once food intake is properly managed, an effort should be made to reduce
the weight of an obese person through physical labor and exercising. Routine physical
labor consumes extra fat cells therefore causing a noticeable reduction in weight. To add to
this endeavor, regular physical exercises would further the use of stored calories.
The most effective therapy to cure obesity is to change certain behavior
patterns. An obese individual should lower their food intake, consuming low calorie food,
use of a clinically proven weight loss product, participating in regular physical work and
exercise three times a week or more.
The intake of lesser food amounts and low calorie food at that will
automatically generate a smaller amount of food energy taken-in therefore causes a person
to be of a lower weight. Care should be taken that the diet is still nutritionally balanced. A
balance must be struck between adequate food and luxury dishes. The obese individual
must take great care in learning about food nutrition. A little amount of nutritional food
would make up a huge intake of junk food. Green vegetables play an important role in the
27
daily meal of an obese. Consumption of green vegetables in place of starchy food aids in
weight loss.
Alcohol should be avoided religiously. All attempts should be made to
avoid getting alcoholic fat cells in the tissues of the body. The overzealous use of
painkillers, sedatives, tranquilizers, anti-depressants and birth control pills should be
stopped if they can be. These drugs cause immense fat as they increase a person’s appetite
and the need to eat more to ease their increased hunger pains.
3.8. Complication
Obesity is a serious illness that can lead to many medical complications.
Unfortunately, it is relatively rare for physicians to treat obesity itself because it requires a
difficult, long-term process to treat effectively. However, treatment for its complications is
done at enormous cost.
1. Hypertension
The etiology of this increase in blood pressure appears to be related to substances
produced by adipose (fat) tissue and to the increase in the hormone insulin that
occurs with obesity. Obese individuals with hypertension should first be treated with
dietary methods in an attempt to reduce their weight. Rather a 10% reduction of
body weight combined with avoidance of excess salt intake can normalize blood
pressure and reduce or eliminate the need for blood pressure medications.
2. Diabetes
Obesity is the leading cause of diabetes. Type 2 of diabetes is almost always
associated with obesity and appears to be related to hormonal substances (cytokines)
produced by adipose (fat) tissue and to the increase amount of blood lipids (fats) that
occurs in diabetes. In the majority of obese individuals with diabetes, reducing body
weight by 10% can eliminate or reduce the need for oral medications or insulin
injections.
3. Elevated cholesterol
28
Elevated cholesterol (hypercholesterolemia) is commonly associated with obesity.
On average, every 10 lbs. of excess fat produces 10 mg. of cholesterol per day. In
other words, putting on 25 extra lbs. leads to the equivalent of taking in one extra
egg yolk per day. Cholesterol levels are determined by both genetics and diet. Two-
thirds of your cholesterol level is genetically determined, while the remaining one-
third is related to diet. Most people can successfully control their cholesterol by
reducing both their fat intake and weight.
4. Fatty Liver (NASH)
Fatty liver disease, more formally known as Non-Alcoholic Steato-Hepatitis
("NASH" - not "nash," the Yiddish word for eating sweets) is caused by excessive
fat deposition in the liver. Excess calorie consumption ("noshing" – the Yiddish
word), can lead to excess fat intake with the fat being stored not only in fat stores,
but also in the liver and other vital organs. This excess liver fat results in silent
inflammation, usually detected by abnormal liver function tests when a blood panel
is performed. If untreated, will go on to develop cirrhosis or liver failure during their
lifetime. Although some diabetic medications are used to treat this condition, the
most effective treatment is weight reduction and increase in physical activity.
5. Metabolic Syndrome (Syndrome X)
To be diagnosed with metabolic syndrome, you need three or more of the following
criteria:
- Waist circumference> 40 inches in men or 35 inches in women.
- Triglycerides > 150 mg/dl.
- HDL cholesterol< 40 mg/dl in men or <50 in women.
- Blood Pressure > 130/85 mm Hg.
- Glucose (fasting) >110 mg/dl.
29
The most effective treatment of metabolic syndrome is weight reduction; alternatively, the
individual conditions are treated with multiple medications and tremendous expense.
6. Cancer
Obesity also results in an increased risk of cancer. In females, there is up to a
threefold increase in the incidence of breast, uterine, cervical, and ovarian cancer.
The risk of endometrial cancer (cancer of the inside lining of the uterus) is up to
seven times higher. For men, there is an increased incidence of colon and prostate
cancer.
7. Degenerative arthritis
Obesity is frequently complicated by degenerative arthritis, the "wear-and-tear"
form, more formally known as osteoarthritis. Increased weight causes more wear
and tear on the joints. Adipose tissue also produces substances (cytokines) that
"destroy" the normal cartilage in joints. If a person loses weight, the wear and tear
gradually diminishes and the amount of cytokines released from adipose tissue
diminishes. The arthritic destruction of joints that has occurred over the years does
not disappear; however, the joint pain will generally diminish since there is less
stress and destruction of the joints.
8. Gallstones
Obesity is frequently complicated by gallstones. Approximately 25% of obese
individuals have gallstones, often resulting in surgery. The increase in cholesterol
that results from obesity is one of the major reasons for the increased incidence of
gallstones.
9. Heart attacks and strokes
There is an increased incidence of strokes and heart attacks in obese individuals.
This increase is both independent of and additive to the increased risk associated
with the elevated blood pressure, diabetes, and elevated cholesterol frequently
30
associated with obesity. This increased risk appears to be related to substances
produced by adipose (fat tissue) that make it easier for blood clots to form. Overall,
obesity results in premature death. As a general rule, for every pound
(approximately 1/2 kg.) over your ideal body weight, subtract one month from your
life expectancy.
10. Sleep disorders
As people gain weight, many complain that they feel tired all the time and may have
problems obtaining a restful sleep. Problems with sleep may be indicative of a
severe condition called Pickwickian Syndrome, or sleep apnea. For people with this
problem, it becomes progressively more difficult to breathe (especially at night) as
their weight increases. These people typically snore severely and have episodes
when they stop breathing completely, sometimes for up to one minute at a time.
During these apneic (not breathing) periods, heart rhythms may become very
irregular, which can lead to a fatal heart attack. People affected with sleep apnea
transiently awaken when they resume breathing. This may occur hundreds of times
per night, causing the afflicted individual to feel tired the next day. Sometimes,
these individuals will fall asleep while sitting in meetings or driving. Sleep apnea is
a very serious complication of obesity and requires professional medical attention.
The best method of treatment is weight reduction; however, other measures are
available to improve the breathing process and help prevent the heart irregularities
that frequently complicate this condition.
11. Depression
People with lesser degrees of obesity may also have problems sleeping. Sleep
disturbances are also associated with anxiety and depression. Depression is not just
feeling blue for a day, but is the result of actual chemical changes that take place in
the brain, causing profound episodes of sadness, crying, and loss of energy.
Depression is a medical condition that requires medical treatment. There are
effective non-addicting medications available if depression is complicating obesity.
3.9. Prevention
31
Primary prevention
While obesity has dual origins relating to both genetics and the
environment, these factors are inextricably linked. The genes provide the gun and the
environment pulls the trigger.
There is no doubt that the problem we face today is related to our modern
western environment. We live in a world of plentiful and attractive energy dense foods,
and a working and leisure environment that encourages sedentary behaviour. Solutions will
require involvement within our communities at many levels. Solutions need to range from
legislation to protect our children from the bombardment of advertising from processed
food manufacturers, and provision of achievable physical activity guidelines for our
kindergartens and schools as an essential part of the daily activities, to local town planning
of our living environments to provide attractive, safe, user friendly areas for active leisure
and physical activity.
Secondary Prevention
Interventions to prevent or control disease are usually most effective, and
perhaps most cost effective, if delivered to a high-risk population. Diabetes prevention
studies have clearly demonstrated the value of such targeting. Modest weight loss,
achieved through lifestyle change, has reduced the number of people with impaired fasting
glucose which leads to the development of type-2 diabetes.
CHAPTER 4
THE CORRELATION BETWEEN HIGH BLOOD PRESSURE AND OBESITY
32
FOR CHILDREN AT THE AGE OF 10 IN SOUTH JAKARTA IN 2005
4.1. Cases
The worldwide prevalence of obesity and its associated metabolic and
cardiovascular disorders has risen dramatically during the past two decades. Our objective
is to review the mechanisms that link obesity with hypertension and altered kidney
function. Current evidence suggests that excess weight gain may be responsible for 65-
75% of the risk for essential hypertension.
Being obese more than doubles the risk of developing raised blood pressure
(hypertension). Obesity research indicates that about 70 percent of obese men and women
suffer from hypertension. For example: the prevalence of hypertension in adults who are
not overweight (body mass index <25) is 14.9 percent for men and 15.2 percent for
women. In contrast, the prevalence of raised blood pressure levels in adults who are obese
(body mass index > 30) is 41.9 percent for men and 37.8 percent for women. The
prevalence of hypertension increases with the degree of obesity.
Morbid or severe clinical obesity is a significant contributor to
cardiovascular disease (inc. heart attacks and stroke) because it is associated with increased
prevalence of cardiovascular risk factors such as raised blood pressure, low levels of high
density lipoprotein (HDL) cholesterol, type 2 diabetes, hypertriglyceridemia,
hyperinsulinemia and insulin resistance. Hypertension means having: average systolic
blood pressure > 140 mm Hg, average diastolic > 90 mm Hg, or currently taking anti-
hypertensive medication.
4.2. Pathology
Excess weight gain is a major cause of increased blood pressure in most patients
with essential hypertension, and also greatly increases the risk for renal disease. Obesity
raises blood pressure by increasing renal tubular reabsorption, impairing pressure
natriuresis, causing volume expansion due to activation of the sympathetic nervous system
and renin-angiotensin system, and by physical compression of the kidneys, especially
when visceral obesity is present. The mechanisms of sympathetic nervous system
33
activation in obesity may be due, in part, to hyperleptinemia that stimulates the
hypothalamic pro-opiomelanocortin pathway. With prolonged obesity, there may be a
gradual loss of nephron function that worsens with time and exacerbates hypertension.
Weight reduction is an essential first step in the management of obesity hypertension and
renal disease. Special considerations for the obese patient, in addition to adequately
controlling the blood pressure, include correction of the metabolic abnormalities and
protection of the kidneys from further injury.
Many medical studies have shown that obesity presented an increase in the cardiac
output and the blood volume, and in the arterial resistance. In fact, obesity induces a high
secretion of insulin in trying to decrease the excessive sugar concentration in the blood.
This insulin secretion is very high compared to a non-obese subject.
Moreover, the insulin, secreted by the pancreas, is responsible for many
modifications in the body:
- It induces a thickening of the vessels which is responsible for an increase in
their rigidity, thus increasing the blood pressure;
- It increases the cardiac output, because the secretion of adrenalin is
increased;
- It induces the reabsorption of water and salt by the kidney, which increases
the blood volume and thus increases the blood pressure;
- Moreover, obesity is responsible for an over-sensitiveness to sodium, which
is known to increase the rigidity of the peripheral arteries.
After some time, the obese subject will develop a natural resistance to the insulin which
will lead his body to synthetize more insulin, thus generating a rise in the blood pressure
by the way of the mechanisms described above.
Excess weight gain accounts for as much as 65-75% of the risk for essential
hypertension and also greatly increases the risk for end stage renal disease (ESRD).
