Management of the obese diabetic patient

Obesity is a well-known risk factor for the development of diabetes. The ma nagement of the obese diabetic patient is a challenge for the clinician. St rategies for dealing with this risk factor include the following: 1) promot ing weight loss through the use of lifestyle modification (hypocaloric diet and exercise), very-low-calorie diets, anti-obesity drugs, and, in well-se lected cases, bariatric surgery; 2) improving glycemic control through redu ction of insulin resistance (lifestyle modifications, metformin, insulin se nsitizers such as thiazolidinediones, benfluorex), correction of insulinope nia (insulin secretagogues/sulfonylureas or exogenous insulin), and delay i n carbohydrate intestinal absorption (acarbose, miglitol); and 3) treating associated risk factors, such as arterial hypertension and dyslipidemias, t o improve the cardiovascular prognosis, Certain methods of improving glycem ic control may unfortunately limit weight reduction or even promote weight gain and worsen risk factors. In the obese patient, selection of an antidia betic 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 morbi d obesity is present, restoring good glycemic control and correcting associ ated risk factors can be done only through drastic weight loss, justifying more aggressive weight reduction programs in well-selected individuals; rem arkable results have been reported with bariatric surgery. In conclusion, e ven though weight loss appears to be the cornerstone of successful treatmen t, long-term prospective studies are needed to determine the place of each strategy in the management of obese diabetic patients.