- Hypertension and diabetes are very common, and they often exist together. Often obesity also coexists with them, that is termed the metabolic syndrome. You specialize in treatment of hypertension in the setting of diabetes and metabolic syndrome What are the nuances of treating hypertension in people who have obesity and metabolic syndrome? First of all, we have to know that the combination, coexistence of hypertension and diabetes is very dangerous. The risk is much higher in diabetic patients when the blood pressure is elevated. So the first point is that we need to lower the blood pressure much more aggressively in diabetic and in obese patients - they are more resistant to hypertension treatment, and it's more difficult to reach the blood pressure goal. If the goal is 130 over 80 in diabetic patients, sometimes they require four or five medications in order to get to the blood pressure target. You have to also know that you don't want to give drugs that may impair the glucose control. So you prefer to choose a type of angiotensin converting enzyme or angiotensin receptor blocker in combination with calcium channel blockers. You try to avoid a beta-blocker as part of the treatment because they impair the glucose metabolism, they increase the Triglycerides. But overall in most of the [diabetes and hypertension] patients you need so many medications that you end up using all the anti-hypertension drugs to control the blood pressure. Patients with obesity - many of them also have sleep apnea. Sleep apnea is one of the causes for treatment-resistant hypertension so it may be more difficult to control the blood pressure in obese patients. Sometimes CPAP may help to control the blood pressure in obese patients with hypertension. CPAP - Continuous Positive Airway Pressure devices... - Yes, right! This is very interesting - sleep apnea in people with obesity... Of course, in normal circumstances the blood pressure dips during the night - so dippers and non-dippers... When someone is "non-dipper" [blood pressure does not become lower during sleep], the first thing that you have to consider is sleep apnea, because those patients with sleep apnea - they don't lower the blood pressure during night. If you use the CPAP, you can improve the blood pressure control - so this is one thing that you have to take into consideration [in hypertension treatment with diabetes and obesity]