Obesity, metabolism, and hypertension

The relationship between obesity and hypertension is complex and poorly understood. A developing body of information suggests that metabolic factors related to the obese state are importantly involved. The pertinent observations include: (1) Diet influences sympathetic nervous system activity. Fasting suppresses, while carbohydrate and fat feeding stimulate, sympathetic activity. (2) Dietary-induced changes in sympathetic activity contribute to the changes in metabolic rate that accompany changes in dietary intake. (3) Insulin-mediated glucose metabolism in the hypothalamus provides a link between dietary intake and sympathetic nervous system activity. And (4) hyperinsulinemia, a consequence of insulin resistance in the obese, is associated with hypertension. These observations have suggested the following hypothesis. Hyperinsulinemia results in sympathetic stimulation which drives thermogenic mechanisms, thereby increasing metabolic rate. The net result is a restoration of energy balance at the expense of hyperinsulinemia and increased sympathetic activity. Hypertension is thus the unfortunate consequence of hyperinsulinemia, which increases renal sodium reabsorption, and sympathetic stimulation of the heart, kidney, and vasculature. The data on which this hypothesis is constructed are reviewed and the implications discussed.