Management of the unholy trinity diabetes–obesity–hypertension (diabesotension)?


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Yehonatan Sharabi, Head, Hypertension Unit, Sheba Medical Center, Tel Hashomer, 52621 ISRAEL.



Diabetes, obesity and hypertension are common conditions and their concurrence is more common than would have been expected: 15% of the developed world suffer from the triad of “diabesotension”. The pathophysiology involves characteristic neurohormonal profiles that collectively suggest the consideration of diabesotension as a distinct clinical entity. Diabesotensive patients have double the risk of suffering from the micro and macrovascular complications of each of the conditions alone. Therefore, it is critical to reduce their overall risk and provide them with special attention. Studies have shown that the number needed to treat in diabesotension is lower compared to non-obese. Appropriate treatment goals should be set. With regards to hypertension, recent clinical trials point to 130-135/80-85 mmHg. Lifestyle modifications are critical, therefore DASH and Mediterranean diet should be recommended along with a physical training program. Weight reduction strategies often fail and bariatric surgery should be considered. All antihypertensive drug-classes are adequate to treat uncomplicated diabesotension and it is not mandatory to include RAAS blockers as first-line therapy. However, as second line, for high risk patients and patients with nephropathy – a RAAS blocker is indicated. Combination therapy is almost always prescribed in the course of the disease. In the absence of compelling indications, a RAAS blocker with a calcium-channels blocker is preferred as it provides benefits beyond blood pressure control. Resistant hypertension is common, and secondary causes should be looked for, particularly sleep apnea. A novel procedure such as renal denervation is a promising option due to its antihypertensive and metabolic benefits.

Copyright © 2012 John Wiley & Sons, Ltd.