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Obesity is a modern epidemic that is fuelling the alarming rise in diabetes prevalence. Furthermore, there is strong evidence that reducing obesity will lead to a reduction in Type 2 diabetes. It is also established that bariatric surgery in a person with Type 2 diabetes can lead to substantial weight loss and amelioration of the disease; some people post-surgery are able to come off all diabetes medications. In this issue (page 628) we publish an International Diabetes Federation (IDF) position statement on the use of bariatric surgery in people with obesity and Type 2 diabetes. This is an important guide to the appropriate use of this valuable surgical procedure in this group of patients and is a welcome addition to the literature. Jon Pinkney will further explore the place of the surgical treatment of obesity in a commentary in next month’s Diabetic Medicine (July 2011).

Despite the success of bariatric surgery, it is important to consider how weight loss may be achieved by individuals with, or at risk of, Type 2 diabetes. Lifestyle modifications should be recommended, even after diabetes is established, but their full potential in achieving weight loss is negated in our modern society by urban design, promotion and ease of access to unhealthy foods, as well as societal and personal attitudes to exercise. A healthy lifestyle may be costly to achieve, with rising food prices and the expense of exercise programmes; factors that are further compounded by the current economic climate. The current UK government promotes the concept of the ‘Big Society’ yet also recommends that obese individuals take personal responsibility for their lifestyle. While individual motivation and action is imperative, it is equally clear that government has a responsibility to promote exercise and find novel ways of encouraging consumption of healthy foods that would include making them more affordable, whilst raising costs and limiting promotion of unhealthy foods. Appropriate regulation of the food industry is key to such ideals, and government must facilitate this transition, however unpopular this action may be. Such strategies are deemed acceptable to restrict tobacco use, so why not dia-obesogenic foods?

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What are the other non-surgical therapeutic options in Type 2 diabetes in people who are overweight or clinically obese? Unfortunately, at the present time, there is not an anti-obesity drug of the same clinical effectiveness as statins are for the prevention of cardiovascular disease in diabetes. Many guidelines recommend that exanatide and liraglutide can be employed as a useful adjunct to therapies in Type 2 diabetes and indeed can aid weight loss. Three articles in the current issue of Diabetic Medicine explore this issue further. Schmidt et al. (page 715) report greater patient satisfaction with the use of liraglutide compared with exanatide, whilst Wysham et al. (page 705), in an open-label extension of the DURATION-2 trial, found patients who switched to once-weekly exenatide from daily sitagliptin or pioglitazone had improved glycaemic control with weight loss. Obesity and glycaemic control remain problematic in Prader–Willisyndrome; Cyganek et al. (page 755) describe the successful use of metformin and liraglutide in one case of someone with this disorder.

It is a common misconception that the reason that people who are obese have difficulty losing weight is because of a ‘lack of will’. Obesity is a classic multifactorial disease with strong genetic and environmental influences on complex physiological mechanisms regulating energy expenditure, appetite and behaviour. FTO is one of many genes that have been implicated in the genetic susceptibility to obesity. In this issue of Diabetic Medicine, Rees et al. (page 673) report a strong association between an FTO variant and both BMI and waist circumference. They also find an association between this variant and Type 2 diabetes, but only partially accounted for by the association with BMI, which is in contrast to that found in Europeans.