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Treatment of Type 2 Diabetes Mellitus: A Weighty Enigma

Richard J. Comi, MD
[+] Article, Author, and Disclosure Information

From Dartmouth Hitchcock Medical Center, Lebanon, NH 03756.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Richard J. Comi, MD, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756.

Ann Intern Med. 2005;143(8):609-610. doi:10.7326/0003-4819-143-8-200510180-00012
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Successful treatment of the central clinical issues in type 2 diabetes—hyperglycemia and obesity—is difficult, elusive, and often enigmatic. Lifestyle change is difficult, and most pharmacologic treatment options cause weight gain. Faced with an obese patient with failing glucose control, clinicians must decide whether a further reduction in average glucose level by 10 mg/dL to 20 mg/dL is worth another 10 pounds of weight gain. Why do we find ourselves facing this therapeutic dilemma? First, our knowledge of the pathophysiology of type 2 diabetes is largely descriptive rather than mechanistic. We know about insulin resistance and defective insulin secretion, but we do not understand their causes in enough depth to target the defects precisely. Second, poor lifestyle choices continue to undo the benefits of our treatments. Sustaining the changes in behavior that are required to improve diet and exercise is exceedingly difficult for patients.

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