A.G. is a 47-year-old white man with a history of type 2 diabetes diagnosed at age 30. At his visit in July 1996, he weighed 275 lb with a height of 6'0” (BMI 37 kg/m2) and had measured A1C of 8.7%, mildly elevated triglycerides and LDL cholesterol, low HDL cholesterol, and normal transaminase levels. He had no signs or symptoms of complications from his disease and felt well. Over the years, his history has been one of variable follow-up in the office with nonadherence to his diet and exercise regimen. His A1C results have fluctuated from 8.0 to 11.5%, his weight has remained > 250 lb, and his medical regimen has intensified to include an ACE inhibitor, a statin, aspirin, a sulfonylurea, and the maximum dose of metformin. In February 2003, after 18 months of absence from follow-up, a bedtime dose of insulin glargine was added to A.G.'s regimen when he presented with thirst, polyuria, and weight loss to 221 lb. His A1C result was 10.6%, and liver function tests revealed aspartate aminotransferase (AST) of 67 units/l and alanine aminotransferase (ALT) of 78 units/l. He had early symptoms of sensory neuropathy in the …