The fields of obesity, diabetes, and hypertension are gaining major attention in the last 2 decades, since the obesity epidemic is driving a parallel increase in related morbidity. Recent progress in the research of these inter-related conditions is bringing a tremendous expansion of basic and clinical data alongside a wealth of novel technologies introduced for the investigation, monitoring, and treatment of these entities. The recent flux of novel insights, treatment modalities, and clinical observations, many of which have major implications that may change clinical practice, raises a significant number of questions by clinicians. The first Controversies in Obesity, Diabetes and Hypertension (COHDy) meeting, held in Berlin in October 2006, was designed as an exclusive forum where world experts and opinion leaders from the three disciplines met to discuss their current insights and experience in controversial issues relevant to these fields. The aims of the meeting were to provide clinicians with answers to unresolved questions of clinical relevance, provide a deeper understanding of and ability to integrate novel findings into clinical practice, and consolidate current knowledge by way of evidence-based research. Highlights from the meeting are brought to you in this supplement, including the contents of several debates on urgent clinical questions and summaries of state-of-the-art presentations.
The Diabetes sessions focused on the recent introduction of novel therapeutic modalities, mainly insulin analogs and insulin pump therapy, for diabetes management and their potential introduction into the paradigm of specific clinical scenarios. The roles of novel insulin analogs and continuous subcutaneous insulin infusion in the treatment of patients with type 1 diabetes were debated with regard to their ability to improve metabolic control without increasing the risk for hypoglycemia. The relative advantages and risks of analogs and continuous subcutaneous insulin infusion therapy, novel glucose monitoring technologies, and inhaled insulin were discussed.
The recent introduction of novel therapies for type 2 diabetes raises several questions and options about changing recent practices and redefining clinical targets. The introduction of peroxidase proliferator–activated receptor-γ agonists, insulin, insulin pump therapy, and pharmacological combination therapy early in the course of diabetes was debated. The emergence of novel classes of medications for type 2 diabetes creates an array of treatment options that vary in the individual choice of agents, their timing of introduction to the treatment regimen, and their potential synergism with other established treatment modalities. The advantages of specific choices of combinations and their timing of introduction were presented, while the importance of fasting and postprandial glucose, as well as glucose variability for clinical management, was discussed.
Recent insights and innovations of the pathophysiology of type 2 diabetes, specifically of the inflammatory aspects of the disease, were presented alongside the entity of type 3 diabetes, a combination of endocrine and exocrine malfunction, which seems to be underdiagnosed and is clinically relevant.
The complications of diabetes were discussed in separate individual sessions. The link of oxidative stress to insulin resistance, hypertension, and diabetes were debated and possible treatments to ameliorate its effect were evaluated. The cardio-metabolic effects of the novel cannaboid receptor antagonist rimonabant were presented along with their anti-obesity effect. The prevention and treatment of diabetic nephropathy was debated, with emphasis on the clinical approach and understanding of microalbuminuria and progressive renal failure. Recent advances in the understanding and treatment of diabetic neuropathy were presented as well.
Specific attention was given to cardiovascular complications, including the understanding of their underlying pathophysiology, natural history, and biomarkers of their early development. Targets for prevention and treatment of cardiovascular disease in patients with diabetes were discussed and defined.
Recent findings and insights on the pathophysiology of hypertension, its assessment in clinical practice, and the role of specific pharmacological combinations in the management of patients with diabetes and hypertension were presented.
The Obesity sessions focused on the pathophysiology and different treatment modalities of this common condition. Obesity-related insulin resistance was discussed, raising the question whether insulin resistance is a mere consequence or a driving force of obesity. The role of gut hormones in our understanding of the physiology of eating behavior and the utility and tailoring of specific treatments for obese patients, including behavioral, pharmacological, and surgical modalities, were presented and debated. The focus is set on the appropriate patient selection for different treatment modalities by way of understanding the mechanisms of action as well as the limitations of each option. Conditions related to obesity such as obstructive sleep apnea and early metabolic complications in childhood and the need to treat the metabolically healthy obese were discussed.
This supplement aims to provide answers to burgeoning clinical dilemmas that clinicians treating patients with obesity, diabetes, and hypertension face in daily practice. The controversies are presented alongside the reviews of specific topics and leave the reader to decide what pieces of data are convincing enough to be integrated into their daily practice. We hope that debating clinically relevant controversies and presenting recent scientific innovations and observations on these fascinating topics will promote further discussion and promote crystallization of the wealth of novel information into data-driven modifications of common treatment paradigms.
I.R. has served as a consultant for Johnson & Johnson, Pfizer, Keryx, Andromeda, MSD, and sanofi-aventis. R.W. has no duality of interest to declare.
This article is based on a presentation at the 1st World Congress of Controversies in Diabetes, Obesity and Hypertension (CODHy). The Congress and the publication of this article were made possible by unrestricted educational grants from MSD, Roche, sanofi-aventis, Novo Nordisk, Medtronic, LifeScan, World Wide, Eli Lilly, Keryx, Abbott, Novartis, Pfizer, Generx Biotechnology, Schering, and Johnson & Johnson.