484
Original Contributions
Close Correlation of Intra-abdominal
Fat Accumulation to Hypertension in
Obese Women
Hideyuki Kanai, Yuji Matsuzawa, Kazuaki Kotani, Yoshiaki Keno, Takashi Kobatake,
Yoshiyuki Nagai, Shigenori Fujioka, Katsuto Tokunaga, and Seiichiro Tarui
Downloaded from http://hyper.ahajournals.org/ by guest on June 15, 2017
The relation between intra-abdominal visceral fat accumulation and blood pressure was
investigated in 67 obese women (mean body mass index, 33.6±3.1; average age, 50±ll years).
As an index of intra-abdominal fat accumulation, the ratio of the intra-abdominal visceral fat
area to subcutaneous fat area was determined using a computed tomographic section at the
level of the umbilicus. When the obese subjects were divided into a hypertensive group and a
normotensive group, the ratio of the intra-abdominal visceral fat area to subcutaneous fat area
in the hypertensive group was significantly higher (0.53±0.33 versus 0.29±0.12, p<0.01).
Significant correlations between the ratio of intra-abdominal visceral fat area to subcutaneous
fat area and systolic blood pressure (r=0.62, p< 0.001) and diastolic blood pressure (r=0.53,
p< 0.001) also were found. However, no significant difference existed in either the body mass
index or the waist-to-hip circumference ratio between the hypertensive and normotensive
groups. Plasma renin activity, aldosterone, epinephrine, and norepinephrine levels were not
significantly different between the two groups. Moreover, the correlation between the ratio of
the intra-abdominal visceral fat area to subcutaneous fat area ratio and blood pressure was
found independent of age and body mass index by multiple regression analyses. We conclude
that intra-abdominal fat accumulation itself may play an important role in the pathogenesis of
hypertension in obesity. (Hypertension 1990;16:484-490)
I
t has been noted that the incidence of circulatory
and metabolic complications among comparably
obese subjects differs depending on their body
habitus.1 We have developed a method to estimate fat
distribution using computed tomography (CT) scan,
which clearly distinguishes between subcutaneous fat
and intra-abdominal visceral fat2 and have demonstrated a close correlation between intra-abdominal
fat accumulation and metabolic disturbances.3 Further, using this method we reported that the accumulation of intra-abdominal visceral fat itself may reflect
cardiac dysfunction and metabolic disorders better
than subcutaneous fat.4-7 Therefore, we propose the
existence of two types of obesity: visceral fat obesity,
characterized by a pronounced accumulation of fat in
the abdominal cavity, and subcutaneous fat obesity,
From The Second Department of Internal Medicine, Osaka
University Medical School, Fukushima-ku, Osaka, Japan.
Presented in part at the 62nd Annual Scientific Sessions of the
American Heart Association, New Orleans, Louisiana, November
13-16, 1989.
Address for correspondence: Hideyuki Kanai, MD, The Second
Department of Internal Medicine, Osaka University Medical
School, 1-1-50 Fukushima, Fukushima-ku, Osaka 553, Japan.
Received March 7,199O, accepted in revised form June 15,1990.
characterized by an accumulation mainly in the subcutis (Figure 1). We also reported8 that this classification is more useful than other classifications of fat
distribution,9"16 including the waist-to-hip circumference ratio, as we were unable to duplicate the correlation between waist-to-hip circumference ratio and
metabolic disorders reported by Kissebah and others.10-11 In the present study, we evaluate the relation
between intra-abdominal fat accumulation and blood
pressure levels in obese Japanese women.
Methods
Subjects
The research subjects were 67 obese adult women
aged 50±ll (range, 31-73) years who consulted our
clinic in the Second Department of Internal Medicine, Osaka University Hospital, Osaka, Japan, for
assistance in weight reduction. Obese patients whose
body mass index (BMI) weight/height2 [kg/m2]) was
more than 30 were considered for the present study.
Their mean BMI was 33.6±3.1 (30.0-44.3). Ten
patients were taking antihypertensive medication
prescribed elsewhere at the start of the study: two
were treated with diuretics, one with a /3-blocker, two
Kanai et al
Visceral fat obesity
Hypertension and Fat Distribution
Subcutaneous fat obesity
Downloaded from http://hyper.ahajournals.org/ by guest on June 15, 2017
with calcium antagonists, and five with combination
therapy. None of the patients were taking any lipidlowering or hypoglycemic agents. The body weight of
the research subjects was stable for at least 4 weeks
before they consulted our clinic, and the study was
performed within 1 week after consultation while the
subjects were maintained on a 2,000 to 2,400 kcal of
a weight-maintaining diet, with 60% of the calories
given as carbohydrate, 20% as fat, and 20% as
protein. None of the subjects engaged in a program
of vigorous physical exercise. All subjects gave informed consent before the investigation.
Procedure
The blood pressure measurements were taken
from the right arm using a mercury manometer after
the subject had briefly rested in a sitting position.
Cuff sizes were selected based on upper-arm girth
and length. The diastolic blood pressure was recorded when the Korotkoff sounds disappeared
(phase five). The mean of three measurements was
used in the analysis. A systolic blood pressure of 160
mm Hg or more or a diastolic blood pressure of 95
mm Hg or more, or both, were defined as hypertension. The subjects meeting these criteria and those
maintained on antihypertensive agents were defined
as hypertensive. A systolic blood pressure less than
140 mm Hg or a diastolic blood pressure less than 90
mm Hg, or both, were defined as normotension. The
blood pressure levels that did not meet the criteria of
hypertension or normotension were defined as borderline hypertension (between 140/90 and 159/94
mm Hg).
Anthropometric measurements included manual
measurements of the height to the nearest 0.1 cm and
weight to the nearest 0.1 kg. Circumferences of the
waist and hip were measured to the nearest 0.1 cm at
the level of the umbilicus and at the widest circumference over the greater trochanters and were used
to calculate the waist-to-hip circumference ratio.
Triceps, subscapular, and periumbilical skinfold
thicknesses were measured to the nearest 1.0 mm
with calipers (Eiyoken-Type, Meikosha Co., Ltd.,
Tokyo), and the mean of two measurements of each
skinfold was used in the analysis. The body fat
distribution by CT scan was determined according to
485
FIGURE 1. Computed tomography
scan at the level of umbilicus comparing (left panel) visceral fat obesity
(54-year-old research subject with a
body mass index (BMI) of 35.4, intraabdominal visceral fat area/subcutaneous fat area (VIS) ratio of 1.75, and
blood pressure of 184/114 mm Hg) and
(right panel) subcutaneous fat obesity
(33-year-old research subject with a
BMI of 34.1, VIS ratio of 0.21, and
blood pressure 136/80 mm Hg) in
obese Japanese women.
the procedure of Tokunaga et al,2 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 subject in the supine position with use of a
General Electric CT/T scanner (General Electric
Co., Milwaukee, Wis.), and the ratio of the intraabdominal visceral fat area to subcutaneous fat area
(V/S ratio) was calculated. The V/S ratio was
adopted as an index of the relative increase of
visceral fat, as previously reported by us3-8 and
others.17-^
Blood was drawn after an overnight fast. Serum
triglycerides, total cholesterol, and uric acid levels
were determined by enzymatic methods. Serum high
density lipoprotein (HDL) cholesterol was measured
by the heparin-calcium precipitation method. A 75 g
oral glucose tolerance test also was performed, and
blood samples were collected at 0, 30, 60,90,120, and
180 minutes to determine glucose and insulin levels.
Plasma glucose was assayed by a glucose oxidase
method and plasma insulin by double antibody radioimmunoassay. The plasma hemoglobin Alc level was
assayed by high-performance liquid chromatography
(HPLC). The plasma glucose area and insulin area
were determined by calculating the area under the
concentration curve (i.e., by multiplying the 30 minutes by the sum of half the fasting level, the levels at
30, 60, 90, and 180 minutes and 1.5 times the level at
120 minutes). The blood samples for plasma renin
activity (PRA), aldosterone, epinephrine, and norepinephrine assays were collected with cold tubes
containing EDTA 2Na (1.5 mg/ml) and stored at
-80° C. PRA and aldosterone concentration were
determined by radioimmunoassay. Plasma epinephrine and norepinephrine were assayed by HPLC.
Statistics
Results are expressed as mean±SD. The significance of differences between means for two groups
was determined by Student's t test for unpaired data
after an analysis of variance. Linear regression analysis was used to study the relation between variances.
Multiple regression analyses were performed to
quantify the effects of age and BMI.
486
Hypertension
Vol 16, No 5, November 1990
TABLE 1. Comparison of Age, Onset of Obesity, Body Measurements, and Fat Distribution Among Hypertensive,
Borderline Hypertensive, and Normotensive Obese Women
Characteristics
Age (yr)
Age of obesity onset (yr)
Systolic BP (mm Hg)
Diastolic BP (mm Hg)
Height (cm)
Weight (kg)
BMI (kg/m2)
WHR
Hypertensive
group
(««33)
53±10*
25±7
163±16
100±8
154.2±4.8
79.1 ±9.0
33J+3.4
1.01+0.07
Borderline
hypertensive
gToup (n=9)
32±8
41 ±8
41±8
0.53±0.33t
31±9
41±10
45±8
0.40±0.12*
Normotensive
group
(«=25)
47±9
27±9
125±11
76±8
156.1±5.0
82.4±10.1
34.1±3.3
0.98±0.08
49±11
27±9
145±9
89±4
153.0±4.8
78.7±9.4
33.3±2.8
0.98 ±0.07
Skinfold thickness
Triceps (mm)
Downloaded from http://hyper.ahajournals.org/ by guest on June 15, 2017
Subscapular (mm)
Periumbilicus (mm)
V/S ratio
31±7
40±9
45±11
0.29±0.12
Systolic and diastolic blood pressures in the hypertensive group were evaluated in those who were not taking
antihypertensive agents (n=23). All values are mean±SD. BMI, body mass index; WHR, waist-to-hip circumference
ratio; V/S ratio, intra-abdominal visceral fat area/subcutaneous fat area ratio.
*p<0.05 versus normotensive group.
tp<0.01 versus normotensive group.
Results
Among the 67 obese research subjects, 33 subjects,
including the 10 taking antihypertensive medication,
were classified as hypertensive, 9 subjects as borderline hypertensive, and the remaining 25 subjects as
normotensive by our criteria. The demographic data
are presented in Table 1. These characteristics were
compared among these three groups. A slight difference in the average age existed between the hyper-
160
so
o
i
V/S RatK)
1 120
TABLE 2. Effect of Body Mass Index, Ratio of Visceral Fat Area to
Subcutaneous Fat Area, and Age on Blood Pressure in Obese
Women as Determined by Multiple Regression Analyses
0.
m
40
0
tensive and normotensive groups, but there was no
significant difference in the age of onset of obesity.
Neither the BMI nor skinfold thickness was significantly different between the two groups. The waistto-hip circumference ratio did not differ in the two
groups. On the other hand, the V/S ratio in the
hypertensive group was significantly higher than in
the normotensive group (0.53±0.33 versus 0.29±
0.12,p<0.01). The V/S ratio in the borderline hypertensive group also was significantly higher than in
the normotensive group. Among the 57 obese subjects who were not taking antihypertensive agents,
there was a significant correlation between the V/S
ratio and systolic blood pressure (r=0.62, p<0.001)
and diastolic blood pressure (r=0.53, p<0.001)
(Figure 2).
As the average age between the hypertensive and
normotensive groups was slightly different, multiple
regression analyses were performed to ascertain
whether the V/S ratio had an independent correlation with systolic or diastolic blood pressure in the 57
subjects. Both the systolic and diastolic blood pres-
1
V/S Ratio
2
FIGURE 2. Scatterplots showing correlation between the
intra-abdominal visceral fat area I subcutaneous fat area (V/S)
ratio and systolic and diastolic blood pressures (BP) in obese
subjects not taking antihypertensive medication.
Blood
pressure
BMI
V/S ratio
Age
Multiple
correlation
coefficient
Systolic
Diastolic
-0.07
-0.11
0.59'
0.52*
0.07
0.02
0.62*
0.56*
Partial correlation coefficient
Ten subjects who were taking antihypertensive agents were not
included in these analyses (n=57). BMI, body mass index; V/S
ratio, ratio of intra-abdominal visceral fat area to subcutaneous fat
area.
•p<0.001.
Kanai et al
Pr»-m«nop«B«l
Hypertension and Fat Distribution
487
Pott-mmpmad
FIGURE 3. Scatterplots showing
correlation between the intra-abdominal visceralfat area/subcutaneous fat
area (V/S) ratio and systolic and
diastolic blood pressures (BP) inpremenopausal (n=24) and postmenopausal (n=33) obese women not taking antihypertensive agents.
Downloaded from http://hyper.ahajournals.org/ by guest on June 15, 2017
sures correlated significantly with the V/S ratio after
adjustment for age and BMI (Table 2).
The 57 subjects also were divided into a premenopausal group (n=24) with regular menstrual cycles
and a postmenopausal group (n=33); the relation
between the V/S ratio or waist-to-hip circumference
ratio and blood pressure was evaluated in each
group. In the 57 subjects, there was no one with
pathological amenoirhea. Both the V/S ratio and the
waist-to-hip circumference ratio in the postmenopausal group were slightly greater than in the premenopausal group, but the differences were not
significant (V/S ratio, 0.48±0.31 versus 0.37±0.26;
waist-to-hip circumference ratio, 1.00±0.07 versus
0.97±0.07). The correlation coefficient between the
V/S ratio and blood pressure also was significant in
both the premenopausal and postmenopausal groups
(Figure 3). On the other hand, the correlation between the waist-to-hip circumference ratio and
blood pressure was not significant in any group
(Figure 4).
To investigate the pathogenetic relation of metabolic and hormonal factors to hypertension, we compared various metabolic characteristics among the
hypertensive, borderline hypertensive, and normotensive groups excluding subjects who were taking antihypertensive medication (Table 3). There
were no significant differences among these three
groups in measured metabolic parameters concerning glucose and lipids metabolism. The hormonal
factors relating to blood pressure regulation were
also compared among these three groups (Table 4).
No significant differences in PRA, aldosterone,
epinephrine, or norepinephrine existed among
these three groups.
Discussion
In the present study, which dealt with severely
obese women, we found that intra-abdominal fat
Post-merapausd
Pro-manopausd
FIGURE 4. Scatterplots showing
correlation between the waist-to—
hip circumference ratio (WHR) and
systolic and diastolic blood pressures
(BP) in premenopausal (n=24) and
postmenopausal
(n=33) obese
women not taking antihypertensive
agents.
120 -
80
r—0.16
MS
40
'•
0.7
1.0
WHR
1.3
488
Hypertension
Vol 16, No 5, November 1990
TABLE 3. Metabolic Characteristics of Obese Subjects in Hypertensive, Borderline Hypertensive, and Normotensive Groups
Characteristics
Fasting plasma glucose
(mg/dl)
Fasting plasma IRI
(microunits/ml)
Plasma glucose area
(mg-min/dl)xlO~ 2
Normotensive
group
("=25)
Hypertensive
group
(n=23)
Borderline
hypertensive
group
106±23
110±16
101±12
13 + 7
12±9
12±6
293±99
316±105
265±101
114+58
110±38
6.5+0.6
107+57
215±14
158+77
210+40
156±94
49±11
50±ll
53±12
5.9±1.8
5.7±2.0
6.1±1.9
("=9)
Plasma insulin area
(microunits • min/
ml)xl(r2
Hemoglobin Ale (%)
Downloaded from http://hyper.ahajournals.org/ by guest on June 15, 2017
Total cholesterol
(mg/dl)
Triglycerides (mg/dl)
HDL cholesterol
(mg/dl)
Uric acid (mg/dl)
6.6+1.9
223 ±38
6.1±0.5
137±115
Ten subjects who were taking antihypertensive agents were not
included in the hypertensive group. All values are mean±SD. IRI,
immunoreactive insulin; HDL, high density lipoprotein.
accumulation had a close correlation with blood
pressure elevation that was independent of age and
BMI. As sex hormones are known to affect fat
distribution,20 we divided the women into a premenopausal group and a postmenopausal group. The
correlation between intra-abdominal fat accumulation and blood pressure was significant in both
groups. These data suggest that intra-abdominal fat
accumulation may play an important role in the
pathogenesis of hypertension in adult obesity. No
published report has examined this relation in this
population, although some investigators reported this
relation in healthy premenopausal women.21-23
Several reports on white women in Western countries found a strong correlation between the waistto-hip circumference ratio and blood pressure.11-21-23
However, the present study did not find any significant correlation between the waist-to-hip circumference ratio and blood pressure in obese Japanese
women. As no standardized level for measuring the
TABLE 4. Plasma Hormone Levels of Obese Subjects in Hypertensive, Borderline Hypertensive, and Normotensive Groups
Hypertensive
group
("=23)
Normotensive
group
("=25)
PRA (ng/ml/hour)
1.0±0.8
Aldosterone (ng/dl)
7.1±2.5
Borderline
hypertensive
group
(«=»)
1.2±0.5
9.0±3.5
Epinephrine (pg/ml)
Norepinephrine
(pg/ml)
32±18
25±10
7.2±2.9
26±11
363±128
320±64
352±158
Characteristics
1.2±0.7
Ten subjects who were taking antihypertensive agents were not
included in the hypertensive group. All values are mean±SD.
PRA, plasma renin activity.
waist and hip has been established, we also investigated the relation between blood pressure and the
waist-to-hip circumference ratio using the minimum
waist girth and maximum hip girth. Even this measurement, however, failed to show a significant correlation between the waist-to-hip circumference ratio and blood pressure (data not shown).
Why were the results between Japanese and Caucasian women different? The significant correlation
between waist-to-hip circumference ratio and blood
pressure in Caucasian women may be due to the
correlation between the V/S ratio and waist-to-hip
circumference ratio.18 In any case, the V/S ratio as an
index of intra-abdominal fat accumulation might be
the best topographic predictor for morbidity in obesity, including hypertension and metabolic disorders.
Therefore, the correlation between the waist-to-hip
circumference ratio and blood pressure may have the
same implications as the correlation between the V/S
ratio and blood pressure in Caucasian subjects. On
the other hand, as reported previously,8 the correlation between the V/S ratio and waist-to-hip circumference ratio in obese Japanese women was not as
strong as in Caucasian women. (In the present study,
r=0.10, NS.) Consequently, a close correlation between the waist-to-hip circumference ratio and
blood pressure in Japanese subjects would not be
expected.
For the present, it remains to be determined
exactly why intra-abdominal fat accumulation is associated with hypertension, although the following
hypotheses are proposed. Adipocytes in the abdominal cavity are known to be metabolically active and
highly sensitive to lipolytic stimulation by catecholamines and to lipid mobilization.20 It has been shown
that the blood flow rate through mesenteric adipose
tissue is greater than the blood flow rate through
inguinal subcutaneous adipose tissue in rats.24 Also,
we have reported that cardiac output in obese subjects, as estimated by echocardiography, was increased in proportion not only to body weight but
also to the V/S ratio.6'25 These data suggest that the
blood flow through adipose tissue in visceral fat
obesity may be greater than in subcutaneous fat
obesity for the same body weight. The greater degree
of volume overload in the former may be related to
hypertension in obesity.
A number of reports have demonstrated that intraabdominal fat accumulation is associated closely with
metabolic disorders such as insulin resistance, glucose intolerance, and hyperlipidemia.3-5-78-21-23
Reaven26 has proposed a syndrome (with resistance
to insulin-stimulated glucose uptake, glucose intolerance, hyperinsulinemia, increased plasma concentration of very low density lipoprotein triglyceride, decreased plasma concentration of HDL cholesterol,
and high blood pressure) as the syndrome X that
tends to occur in the same individual and may be of
enormous importance in the genesis of coronary
artery disease.26 This syndrome has a similar feature
to visceral fat obesity as this type of obesity fre-
Kanai et al Hypertension and Fat Distribution
Downloaded from http://hyper.ahajournals.org/ by guest on June 15, 2017
quently is associated with both metabolic disorders
and hypertension. Blood pressure in visceral fat
obesity may be increased by various metabolic aberrations, including hyperinsulinemia, insulin resistance, or arteriosclerotic vascular changes that are
accelerated by aging or hyperlipidemia.14-27-30 However, we did not find a significant difference in these
metabolic factors between hypertensive and normotensive groups, suggesting that neither these nor
any metabolic measure in the present study was
directly related to the pathogenesis of hypertension
in obesity.
As a factor that promotes both intra-abdominal fat
accumulation and high blood pressure, an increased
androgenic activity may be proposed as a candidate.20
However, we found a significant correlation between
the V/S ratio and blood pressure in both premenopausal and postmenopausal women. As the postmenopausal group is naturally more androgenic than
the premenopausal group, the significant correlation
between the V/S ratio and blood pressure in both
groups suggests that the correlation is independent of
any androgenic influence. Further study is required
to clarify the pathogenetic relation between intraabdominal fat accumulation and high blood pressure.
In conclusion, the V/S ratio showed a close correlation with blood pressure in obese subjects independent of BMI and age, whereas the correlation between
waist-to-hip circumference ratio and blood pressure
was not significant in these Japanese subjects. There
were no significant differences in either metabolic or
hormonal factors measured here among the hypertensive, borderline hypertensive, and normotensive
groups. These data indicate that intra-abdominal fat
accumulation itself may play an important role in the
pathogenesis of high blood pressure in obesity. Therefore, it will be necessary for the prevention and
treatment of hypertension in obesity to clarify the
pathogenesis of visceral fat accumulation and to find
the most effective method of reducing it.
References
1. Vague J: The degree of masculine differentiation of obesities:
A factor determining predisposition to diabetes, atherosclerosis, gout, and uric calculous disease. Am J Clin Nutr 1956;4:
20-34
2. Tokunaga K, Matsuzawa Y, Ishikawa K, Tami S: A novel
technique for determination of body fat by computed tomography. IntJ Obesity 1983;7:437-445
3. Fujioka S, Matsuzawa Y, Tokunaga K, Tarui S: Contribution
of intra-abdominal fat accumulation to the impairment of
glucose and lipid metabolism in human obesity. Metabolism
1987;36:54-59
4. Tarui S, Fujioka S, Tokunaga K, Matsuzawa Y: Comparison of
pathophysiology between subcutaneous-type and visceral-type
obesity, in Bray GA, LeBlanc J, Inoue S, Suzuki M (eds): Diet
and Obesity. Tokyo, Japan Scientific Societies Press, 1988, pp
143-152
5. Matsuzawa Y, Fujioka S, Tokunaga K, Tarui S: A novel
classification: Visceral fat obesity and subcutaneous fat obesity, in Berry EM, Blondheim SH, Eliahou HE, Shafrior E
(eds): Recent Advances in Obesity Research: V. London/Paris,
John Libbey, 1987, pp 92-%
489
6. Nakajima T, Fujioka S, Tokunaga K, Matsuzawa Y, Tarui S:
Correlation of intraabdominal fat accumulation and left ventricular performance in obesity. Am J Cardiol 1989;64:369-373
7. Matsuzawa Y, Fujioka S, Tokunaga K, Tarui S: Classification
of obesity with respect to morbidity. Asian Med J 1989;32:
435-441
8. Fujioka S, Matsuzawa Y, Tokunaga K, Kawamoto T,
Kobatake T, Keno Y, Tarui S: Comparison of a novel classification of obesity (visceral fat obesity and subcutaneous fat
obesity) with previous classifications of obesity concerning
body features or adipose tissue ccllularity, in Bj&rntorp P,
RCssner S (eds): Obesity in Europe 88. London/Paris, John
Libbey, 1988, pp 85-89
9. Berglund G, Ljungman S, Hartford M, Wilhelmsen L, Bjdrntorp P: Type of obesity and blood pressure. Hypertension
1982;4:692-696
10. Kissebah AH, Vydelingum N, Murray R, Evans DJ, Hartz AJ,
Kalkhoff RK, Adams PW: Relation of body fat distribution to
metabolic complications of obesity. / Clin Endocrinol Metab
1982;54:254-260
11. Kalkhoff RK, Hartz AH, Rupley D, Kissebah AH, Kelber S:
Relationship of body fat distribution to blood pressure, carbohydrate tolerance, and plasma lipid in healthy obese
women. / Lab Clin Med 1983;102:621-627
12. Blair D, Habicht JP, Sims EAH, Syhvester D, Abraham S:
Evidence for an increased risk for hypertension with centrally
located body fat and the effect of race and sex on thisrisk.Am
J Epidemiol 1984;119:526-540
13. Weinsier RL, Norris DJ, Birch R, Bernstein RS, Wang J, Yang
MU, Pierson RN Jr, Van Itallie TB: The relative contribution
of body fat and fat pattern to blood pressure level. Hypertension 1985;7:578-585
14. Bjdrntorp P: Hypertension and other complications in human
obesity. J Clin Hypertens 1986;2:163-165
15. Cigolini M, Seidell JC, Charzewska J, Ellsinger BM, DiBiase
F, Bj6rntorp P, Hautvast JGAJ, Contaldo F, Szostak V, Scuro
LA: Fat distribution, metabolism and plasma insulin in European women: The European fat distribution study, in Bjorntorp P, Rftssner S (eds): Obesity in Europe 88. London/Paris,
John Libbey, 1988, pp 35-41
16. Landin K, Krotkiewski M, Smith U: Importance of obesity for
the metabolic abnormalities associated with an abdominal fat
distribution. Metabolism 1989;38:572-576
17. Dixson AK: Abdominal fat assessed by computed tomography:
Sex difference in distribution. Clin RadUA 1983;34:189-191
18. Ashwell M, Cole TJ, Dixon AK: Obesity: New insight into the
anthropometric classification of fat distribution shown by
computed tomography. Br Med J 1985;290:1692-1694
19. Sjostrom L, Kvist H, Cederblad A, Ty!6n U: Determination of
total adipose tissue and body fat in women by computed
tomography, *°K, and tritium. Am J Physiol 1986;250:
E736-E745
20. Evans DJ, Hoffman RG, Kalkhoff RK, Kissebah AH: Relationship of androgenic activity to body fat topography, fat cell
morphology, and metabolic aberration in premenopausal
women. / Clin Endocrinol Metab 1983^7:304-310
21. Seidell JC, Bjdrntorp P, Sjostrom L, Krotkiewski M, Sannerstedt R: Abdominal obesity and metabolism in men. Possible
role of behavioural characteristics, in BjOrntorp P, R&ssner S
(eds): Obesity in Europe 88. London/Paris, John Libbey, 1988,
pp 91-99
22. Peiris AN, Hennes MI, Evans DJ, Wilson CR, Lee MB,
Kissebah AH: Relationship of anthropometric measurements
of body fat distribution to metabolic profile in premenopausal
women. Ada Med Scand 1989;723(suppl):179-188
23. Peiris AN, Sothmann MS, Hoffmann RG, Hennes MI, Wilson
CR, Gustafson AB, Kissebah AH: Adiposity, fat distribution,
and cardiovascular risk. Ann Intern Med 1989;110:867-872
24. Herd JA, Goodman HM, Grose SA: Blood flow rates through
adipose tissues of unanesthetized rats. Am J Physiol 1968;214:
263-268
25. Nakajima T, Fujioka S, Tokunaga K, Hirobe K, Matsuzawa Y,
Tarui S: Noninvasive study of left ventricular performance in
490
Hypertension
Vol 16, No 5, November 1990
obese patients: Influence of duration of obesity. Circulation
1985;71:481-486
26. Reaven GM: Role of insulin resistance in human disease.
Diabetes 1988;37:1595-1607
27. De Fronzo RA: Insulin and renal sodium handling: Clinical
implications. Int J Obesity 1981;5(suppl l):93-104
28. Manicardi V, Camellini L, Bellodi G, Coscelli C, Ferrannini E:
Evidence for an association of high blood pressure and
hyperinsulinemia in obese man. / Clin Endocrirwl Metab
1986;62:1302-13O4
29. Dornfeld LP, Maxwell MH, Waks A, Tuck M: Mechanisms of
hypertension in obesity. Kidney Int 1987;32(suppl 22):
S254-S258
30. Kanai H, Kobatake T, Nakamura T, Funahashi T, Fujioka S,
Nakajima T, Tokunaga K, Matsuzawa Y, Tarui S: Close
correlation of fasting insulin levels to blood pressure in obese
children (abstract). Circulation 1987;76(suppl IV):IV-18
KEY WORDS • essential hypertension • obesity • adipose tissue
Downloaded from http://hyper.ahajournals.org/ by guest on June 15, 2017
Close correlation of intra-abdominal fat accumulation to hypertension in obese women.
H Kanai, Y Matsuzawa, K Kotani, Y Keno, T Kobatake, Y Nagai, S Fujioka, K Tokunaga and S
Tarui
Hypertension. 1990;16:484-490
doi: 10.1161/01.HYP.16.5.484
Downloaded from http://hyper.ahajournals.org/ by guest on June 15, 2017
Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 1990 American Heart Association, Inc. All rights reserved.
Print ISSN: 0194-911X. Online ISSN: 1524-4563
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://hyper.ahajournals.org/content/16/5/484
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in
Hypertension can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial
Office. Once the online version of the published article for which permission is being requested is located, click
Request Permissions in the middle column of the Web page under Services. Further information about this
process is available in the Permissions and Rights Question and Answer document.
Reprints: Information about reprints can be found online at:
http://www.lww.com/reprints
Subscriptions: Information about subscribing to Hypertension is online at:
http://hyper.ahajournals.org//subscriptions/