Type 2 diabetes is increasing in prevalence and is associated with, amongst others, premature CVD, retinopathy and kidney failure. The aim of care is to minimise the complications through euglycaemia but in the long term, this is rarely possible. Treatment of hypertension and dyslipidaemia also has benefit and patients are often consigned to a lifetime of polypharmacy. Quality of life is affected, especially in those with complications and in those who need treatment with insulin. Therapy with some second line drugs (sulphonylureas, thiazolidinediones and insulin) often results in weight gain. Novel treatment modalities are being sought and newer agents, such as thiazolidinediones, GLP-1 receptor agonists and DPP-IV inhibitors, exploit mechanisms of action different to those of older drugs. Bariatric surgery is increasingly performed and Roux-en-Y Gastric Bypass (RYGB) is the surgical procedure for which the evidence base is greatest, with reported diabetes remission rates of >80%. Most evidence derives from people who also had morbid obesity but recently, patients with lower BMIs have been studied. Irrespective of initial body weight, RYGB is followed by a fall in insulin resistance, detectable within days of surgery and thus unlikely to be caused simply by weight loss. There is also an improvement in insulin secretion including restoration of the first phase loss of which had previously been considered irreversible. Multiple questions remain, however, before advocating RYGB generally in diabetes management (in the absence of morbid obesity). Principal amongst these is the lack of randomised controlled trials comparing surgery with modern intensive medical management. RYGB is essentially irreversible and long term data are scanty. We do not know the subgroups of patients who will benefit most and management strategies for care following operation have not been defined. Comparisons of life quality and economic data are also scanty. While promising, much remains to be learned.