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Management of diabetes mellitus.

DIETARY MODIFICATION. Dietary control is important in both type 1 and type 2

diabetes. The goals of dietary modification are to maintain glucose
concentrations in the normal range or as close to normal as possible, and a lipid
and lipoprotein profile and blood pressure that reduce the risk of macrovascular
disease (see Diabetic Complications, ). Correction of obesity is desirable in
all patients, and weight loss in patients with type 2 diabetes can decrease insulin
resistance, improve glycaemic and lipid measures, and reduce blood pressure.
Anorectic drugs are not effective in promoting weight loss in these patients,11
although orlistat, a gastric and pancreatic lipase inhibitor, can be used as an adjunctive
treatment to reduce weight and improve blood glucose control in overweight patients
with type 2 diabetes.12-14 A high fibre intake may also lower blood-glucose
concentrations and additional fibre is sometimes taken in the form of guar gum (see
). The influence of diet on diabetes is such that all diabetic patients need to be
aware of the composition of foods and to be able to make adjustments to their diet,
especially to counteract treatment-induced hypoglycaemia. Controversy continues,
however, as to the optimum composition of the diet in diabetics, and in particular the
relative contribution of calories from fat and from carbohydrate.

EXERCISE. All diabetic patients should be encouraged to exercise, according to

their age and physical capability.5 Exercise improves carbohydrate metabolism,
insulin sensitivity,15,16 and cardiovascular function.17 It is also a useful component
of any weight reduction programme although diet is more effective in promoting
weight loss and metabolic control.11

ORAL ANTIDIABETICS. If patients with type 2 diabetes have not achieved suitable
control after about 3 months of dietary modification and increased physical
activity, then oral antidiabetics (oral hypoglycaemics) may be tried. The two
major classes are the sulfonylureas and the biguanides. Sulfonylureas act mainly
by increasing endogenous insulin secretion, while biguanides act chiefly by
decreasing hepatic gluconeogenesis and increasing peripheral utilisation of
glucose. Both types function only in the presence of some endogenous insulin
production. More recently developed classes of oral antidiabetics include the
alpha-glucosidase inhibitors, the meglitinides, and the thiazolidinediones. Alpha-
glucosidase inhibitors act by delaying the absorption of glucose from the
gastrointestinal tract; meglitinides increase endogenous insulin secretion; and
thiazolidinediones appear to increase insulin sensitivity.