Xiao Zhang is 26 years old, a real post-90s, ready to jump to an investment company. When he was about to start, the company sent a letter of rejection because Zhang had been checked for hypertension during his medical checkup. High blood pressure? Isn’t this the patent of the elderly? In fact, in clinical practice, we encounter a lot of young people like Xiao Zhang suffering from hypertension! Epidemiological data show that hypertension in China is getting younger and younger, and the prevalence of hypertension among young people is on the rise. Why? Let’s analyze the daily life of Xiao Zhang. When Xiao Zhang just graduated, he was 5’3″ tall and weighed 140 pounds. After working three irregular meals, often stay up late into the night, kebabs and beer became the standard night snack. Long-term stressful work makes his only hobby becomes sleeping. Three years later, Zhang’s weight soared to more than 180 pounds, and his blood pressure soared from 120 or 130 mm Hg in the past to more than 160 mm Hg. Excluding other factors such as genetics and kidney disease, overweight and even obesity are the “culprits” of Xiao Zhang’s elevated blood pressure! Why does obesity lead to high blood pressure? As early as the 1920s, researchers have noted the close relationship between obesity and hypertension. The famous Framingham Heart Study explored the relationship between weight and hypertension and showed that 26% of hypertension cases in men and 28% of hypertension cases in women were caused by being overweight or obese. Obesity can cause elevated blood pressure and make it more difficult to control, and can further increase overall cardiovascular risk and all-cause mortality. Researchers have identified a number of possible pathogenic mechanisms. 1, renin – angiotensin – aldosterone system activation Obese people’s blood pressure can be accompanied by an increase in cardiac output, a relative increase in systemic vascular resistance, renin – angiotensin – aldosterone system activity may increase. 2, hyperinsulinemia and insulin resistance Obese people have insulin resistance, resulting in impaired glucose tolerance and hyperinsulinemia, which may lead to increased sympathetic activity, increased renal reabsorption of sodium resulting in increased volume, vascular endothelial dysfunction, upregulation of angiotensin II receptor expression and reduced cardiac natriuretic peptide, etc., thus raising blood pressure. This mechanism is considered to be an important mechanism for the formation of obesity-related hypertension. 3, leptin – melanocortin pathway leptin is a kind of transmission to the brain about the body fat storage amount signal protein. When obesity increases, leptin increases to convey a stronger negative feedback signal, and leptin increases may raise blood pressure by increasing sympathetic activity. Black corticosteroid receptors may be related to blood pressure regulation, the mechanism is involved in leptin and hyperinsulinemia-induced sympathetic activity increases. 4, other Inflammation/oxidative stress, abnormal extravascular lipid function and sleep apnea syndrome and other factors. What are the new developments in the treatment of obesity-associated hypertension? The intervention strategy for this obesity-associated hypertension should take into account both blood pressure control and improvement of metabolic disorders, and implement the principle of comprehensive intervention and individualized treatment based on lifestyle intervention to comprehensively reduce the total cardiovascular risk. However, the current therapeutic lifestyle changes are effective in the early stage of hypertension but have limited long-term effects, especially for those with moderate to severe obesity and multiple risk factors, combined with target organ damage or clinical complications, and their compliance and efficacy are not satisfactory. For the key target of obesity control, phentermine hydrochloride, bupropion hydrochloride, chlortetracycline hydrochloride, orlistat and other traditional bariatric drugs currently in clinical use, as well as the newly approved GLP-1 receptor agonist liraglutide have certain cardiovascular risks or antihypertensive effects that need to be further determined, limiting their application in obesity-related hypertension. With the rapid growth of the obese population and the introduction of laparoscopic surgery, bariatric surgery is gradually becoming more widespread worldwide. A large body of clinical evidence suggests that surgery is the most effective treatment for metabolic disorders such as obesity, type 2 diabetes, hypertension, dyslipidemia, and obstructive sleep apnea. Therefore, the American College of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery jointly issued a new clinical practice guideline for bariatric surgery in 2013, suggesting that “bariatric surgery” should be renamed “metabolic surgery”. This name change reflects that the indications for metabolic surgery have expanded from the initial weight loss to the treatment of metabolic diseases such as diabetes and hypertension, and also reflects that the focus of metabolic surgery has shifted to the comprehensive control of cardiovascular metabolic abnormalities. In China, a research team followed up 60 patients undergoing laparoscopic bariatric surgery and found that the surgery was effective in controlling hypertension. The related paper was published in the British Journal of Clinical and Experimental Research in Hypertension. The follow-up results showed that 12 months after the surgery, the hypertension cure rate reached 87.1 percent, and 100 percent of the patients’ blood pressure improved. Even some hypertensive patients’ blood pressure returned to normal on the first postoperative day, and a significant reduction in blood pressure was observed within 10 days after surgery. How can blood pressure be affected by surgery on the stomach? Current studies suggest that the mechanism of blood pressure reduction by metabolic surgery is mainly related to the following factors: 1. Weight loss, fat inflammation reduction, and adipokine alteration are important causes and concomitant changes of blood pressure reduction after metabolic surgery. 2.Improved insulin secretion and enhanced insulin sensitivity after surgery are important reasons for the improvement of glucose metabolism, which is also related to the improvement of blood pressure. 3.Changes in gastrointestinal hormones play an important role in the improvement of blood pressure in metabolic surgery. 4.Metabolic surgery can reduce central and peripheral sympathetic nerve activity and improve endothelium-dependent vasodilatory function to lower blood pressure. 5.Sodium-removal diuretic effect: The Swedish SOS cohort study found that gastric bypass had significantly enhanced sodium-removal diuresis and that increased daily urine output correlated significantly with the degree of blood pressure reduction. Of course, patients with hypertension suitable for surgical treatment should first have some degree of obesity. In young patients, hypertension is closely related to endocrine disorders, and surgical treatment will have better results. In contrast, in elderly patients, vascular sclerosis and stenotic changes have occurred, and hypertension may not necessarily improve after weight loss surgery. Therefore, we, as a professional and responsible bariatric metabolic surgery team, must strictly control the indications for surgery.