Management of the obese diabetic patient

Obesity is a well-known risk factor for the development of diabetes. The management of the obese diabetic patient is a challenge for the clinician. Strategies for dealing with this risk factor include the following: 1) promoting weight loss through the use of lifestyle modification (hypocaloric diet and exercise), very-low-calorie diets, anti-obesity drugs, and, in well-selected cases, bariatric surgery; 2) improving glycemic control through reduction of insulin resistance (lifestyle modifications, metformin, insulin sensitizers such as thiazolidinediones, benfluorex), correction of insulinopenia (insulin secretagogues/sulfonylureas or exogenous insulin), and delay in carbohydrate intestinal absorption (acarbose, miglitol); and 3) treating associated risk factors, such as arterial hypertension and dyslipidemias, to improve the cardiovascular prognosis, Certain methods of improving glycemic control may unfortunately limit weight reduction or even promote weight gain and worsen risk factors. In the obese patient, selection of an antidiabetic agent should favor compounds that improve insulin action rather than stimulate insulin secretion, Exogenous insulin alone is rarely successful; combined therapy is often preferable in obese diabetic patients. When morbid obesity is present, restoring good glycemic control and correcting associated risk factors can be done only through drastic weight loss, justifying more aggressive weight reduction programs in well-selected individuals; remarkable results have been reported with bariatric surgery. In conclusion, even though weight loss appears to be the cornerstone of successful treatment, long-term prospective studies are needed to determine the place of each strategy in the management of obese diabetic patients.