Therapeutic challenges in the obese diabetic patient with hypertension

Obesity, diabetes mellitus, and hypertension are common and interrelated medical problems in Westernized, industrialized societies. These medical conditions are associated with an increased risk of cardiovascular disease and are more prevalent among minorities, such as African-American and Hispanic populations. The associated cardiovascular risks of these problems are more thoroughly addressed in another review in this supplement. Obesity markedly enhances the development of type II diabetes. Moreover, it enhances the cardiovascular risk associated with other risk factors, such as hypertension and dyslipidemia. Weight reduction in association with an aerobic exercise program improves metabolic abnormalities and reduces blood pressure in individuals with diabetes and hypertension. Frequently, however, pharmacologic treatment is required to lower blood pressure. Individual therapy with an angiotensin-converting enzyme (ACE) inhibitor is preferred initially in these individuals, with the addition of either a low dose diuretic or a nondihydropyridine calcium antagonist if additional blood pressure reduction is required. These additive agents are recommended, since each has been shown individually to reduce cardiovascular morbidity and to preserve renal function among diabetic patients. Other issues, such as aggressive therapy of lipids and adequate glycemic control, are also important strategies for reducing cardiovascular and renal morbidity and mortality in this very highrisk population.