Therapies and strategies to better treat type 2 diabetes

Answer: The first and most important step in managing type 2 diabetes is lifestyle modification. A balanced diet is essential: it should be rich in fibre, which aids glucose regulation and improves intestinal function, low in simple sugars and saturated fats, and adequate for individual calorie needs, to avoid both deficiencies and excess calories that aggravate body weight. It is recommended to favour wholemeal foods, fresh fruit and vegetables, lean proteins and healthy fats, such as those from extra virgin olive oil and oily fish.

Alongside diet, regular exercise is another fundamental pillar. Physical activity, whether aerobic (brisk walking, swimming, cycling) or endurance (weight training or elastic bands), improves insulin sensitivity, promotes blood glucose reduction and helps lower glycated haemoglobin (HbA1c), an indicator of average blood glucose over the past few months. In addition, exercise helps reduce cardiovascular risk factors such as high blood pressure and LDL-cholesterol levels. Weight loss, even modest but steady, is another very important outcome to pursue: a 5-10% drop in body weight can have a significant impact on glycaemic control and prevention of complications, also improving the patient's quality of life. It is important to remember that quitting smoking is equally crucial, because tobacco aggravates the vascular damage already present in diabetes and increases the risk of cardiovascular events.

Metformin is the first-line drug in most cases, unless there are specific contraindications. It is prized for its efficacy in reducing blood glucose, good safety profile and cardiovascular benefits, which have been demonstrated in some studies. However, as the disease progresses, it may be necessary to combine other drugs. Indeed, increasingly, the inclusion of innovative drugs from the outset may offer an immediate advantage in glycaemic control and cardiovascular and renal protection.

Among the innovative drugs, sodium-glucose cotransporter type 2 (Sglt2i) inhibitors reduce blood glucose via the elimination of glucose with urine and provide significant cardiac and renal benefits. Glp-1 receptor agonists (Glp-1Ra) stimulate insulin secretion in a glucose-dependent manner, promote weight loss and offer cardiovascular and renal protection. Finally, the dual agonists (combining action on Glp-1 and Gip) improve glycaemic control, promote significant weight loss and also confer cardiovascular and renal benefits. All three of these drug classes have revolutionised diabetes therapy, modifying the natural history of the disease and improving patients' prognosis. Dpp-4 inhibitors represent a further option, capable of improving pancreatic beta-cell function and reducing glycaemic peaks, especially postprandial. However, they have not demonstrated significant cardiovascular benefits, although they are generally well tolerated and safe. Only at an advanced stage of the disease or in special situations is insulin also used in type 2 diabetes, to ensure tighter blood glucose control when other therapies are insufficient or contraindicated.

Finally, the treatment of type 2 diabetes cannot be separated from an integrated approach involving a multidisciplinary team of doctors, nurses, dieticians, educators and, when necessary, psychologists.

Monitoring the disease and preventing complications requires constant attention to the various clinical parameters. The goal for HbA1c is generally to maintain values below 6.5%, but this target must be customised according to the patient's age, general condition, presence of other diseases and risk of hypoglycaemia. It is equally important to keep blood pressure under control, with a target value usually below 130/80 mmHg. LDL-cholesterol management is another crucial factor in reducing cardiovascular risk, through proper diet, physical activity and specific medications.