The prevalence of
type 2 diabetes mellitus (T2DM) is rising in association with an increase in
obesity rates. Current treatment options for patients with T2DM include lifestyle modifications and numerous
antidiabetic medications. Despite the availability of effective and well-tolerated treatments, many patients do not achieve recommended glycemic targets. Lack of efficacy is complicated by the wide range of available agents and little specificity in treatment guidelines, thus challenging clinicians to understand the relative benefits and risks of individual options for each patient. In this article, lifestyle intervention strategies and current
antidiabetic agents are evaluated for their efficacy, safety, and
weight-loss potential. Because of the heterogeneous and progressive nature of T2DM, physicians should advocate approaches that emphasize weight management, limit the risk of
hypoglycemia and adverse events, and focus on the core pathophysiologic defects in patients with T2DM. A healthy,
plant-based diet that is low in saturated fat and refined
carbohydrates but high in whole grains, vegetables, legumes, and fruits, coupled with resistance and aerobic exercise regimens, are recommended for patients with T2DM. When necessary,
drug intervention, described in this article as the MGI (
metformin,
glucagon-like peptide-1 receptor agonist, and
insulin) approach, should begin with
metformin and progress to the early addition of
glucagon-like peptide-1 receptor agonists because of their
weight loss potential and ability to target multiple pathophysiologic defects in patients with T2DM. For most patients, treatments that induce
weight gain and
hypoglycemia should be avoided.
Long-acting insulin should be initiated if
glycemic control is not achieved with
metformin and
glucagon-like peptide-1 receptor agonist combination
therapy, focusing on
long-acting insulin analogs that induce the least
weight gain and have the lowest
hypoglycemic risk. Ultimately, a patient-centered treatment approach that addresses the core pathologies of T2DM and
obesity will not only increase overall efficacy and the likelihood that a patient adheres to treatment, but may also improve a patient's mental well-being and quality of life.