The theory of treating Type 2 diabetes

Type 2 diabetes mellitus is a chronic, progressive disease affecting many millions of people worldwide. It carries a great burden of morbidity and premature mortality for the individual, and places great demands on healthcare systems and resources. We now know from clinical studies that improved control of Type 2 diabetes can to some degree reduce its burden. We also know that in the context of a clinical trial, the treatments available to us can do much to improve control in many patients (although all will fall short of 'normality'). International guidelines for management of Type 2 diabetes, quite correctly, encourage us to strive for levels of control where we believe the risk of complications is lowest. But is this happening in everyday practice? Data from a survey in three countries show that there is a great difference between the theory of diabetes care and the reality of clinical practice, with levels of glycaemic control in most patients falling short of desired levels. A consideration of the pathophysiology of Type 2 diabetes reveals that it is a complex syndrome focussing on the progressive failure of the pancreatic beta-cell. By acknowledging this fact, and addressing our therapeutic efforts appropriately, we may help to span the gap between theory and reality.