Diabetes, Endocrine, and Nutrition Center, York Hospital, York, ME 03909, USA.
Postgrad Med. 2013 May;125(3):112-26. doi: 10.3810/pgm.2013.05.2666.
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.
2 型糖尿病（T2DM）的患病率随着肥胖率的增加而上升。T2DM 患者的当前治疗选择包括生活方式改变和多种抗糖尿病药物。尽管有有效的、耐受性良好的治疗方法，但许多患者仍未达到推荐的血糖目标。由于可用药物的范围广泛且治疗指南缺乏特异性，因此治疗效果不理想，这使得临床医生难以了解每个患者的各种治疗选择的相对益处和风险。在本文中，评估了生活方式干预策略和当前的抗糖尿病药物在疗效、安全性和减肥潜力方面的情况。由于 T2DM 的异质性和进行性，医生应提倡强调体重管理、限制低血糖和不良事件风险、并关注 T2DM 患者核心病理生理缺陷的方法。对于 T2DM 患者，推荐采用健康的、植物性饮食，其特点是饱和脂肪和精制碳水化合物含量低，而全谷物、蔬菜、豆类和水果含量高，并结合阻力和有氧运动方案。在必要时，本文中描述的药物干预，即 MGI（二甲双胍、胰高血糖素样肽-1 受体激动剂和胰岛素）方法，应从二甲双胍开始，并尽早添加胰高血糖素样肽-1 受体激动剂，因为它们具有减肥潜力，并且能够针对 T2DM 患者的多种病理生理缺陷。对于大多数患者，应避免使用会导致体重增加和低血糖的治疗方法。如果二甲双胍和胰高血糖素样肽-1 受体激动剂联合治疗不能控制血糖，则应开始使用长效胰岛素，重点是使用引起体重增加最少且低血糖风险最低的长效胰岛素类似物。最终，以患者为中心的治疗方法不仅可以提高总体疗效和患者对治疗的依从性，还可以改善患者的心理健康和生活质量，从而解决 T2DM 和肥胖的核心病理问题。
