The prevalence of Type 2 Diabetes has increased dramatically over the last two decades with a much larger number of patients who are moderately or severely obese. This patient population presents many management challenges as they frequently have other obesity related co-morbidities. Although glycaemic control can be achieved with the addition of insulin or sulphonylureas if metformin is not tolerated or adequate, this leads to further weight gain with a subsequent vicious cycle of further medication escalation and weight gain. Newer pharmacological agents available now are either weight neutral or lead to minimal weight loss. However, if significant weight loss of 10% or greater can be achieved this invariably leads to improved glycaemic control greater than any pharmacological agent available, as well as improvements in other obesity related co-morbidities. This forms the basis for the rationale of classifying Type 2 Diabetes into 2 groups based on BMI, i.e. patients with a BMI less than or greater than 35kg/m2. The practical implications for how to treat each group will be explored.