Help is at hand

Medical Management of Diabetes Mellitusedited by Jack L. Leahy, Nathaniel G. Clark and William T. Cefalu. Marcel Dekker, 2000. US$99.75 (xxiii + 738 pages) ISBN 0824788575Medical Management of Diabetes Mellitus is a great book. In its preface, the authors point out that ‘a worldwide healthcare crisis looms in the form of diabetes mellitus and associated illnesses of insulin resistance.’ They also acknowledge that, ‘the last decade has seen an explosion of new therapies for…diabetes care.’ Thus, there is a constant, bewildering barrage of new information about advances in understanding and treating types 1 and 2 diabetes. Fortunately, help is at hand in the current volume.The goals of the authors as stated in the preface are to ‘provide a comprehensive, up-to-date overview of diabetes mellitus,’ and to give a ‘how-to manual…written by experts…with strong clinical and teaching background.’ They have succeeded, for the most part, in reaching both goals. The introductory chapters on the epidemiology, etiology and care guidelines for patients with diabetes are concisely written, with summaries of the magnitude of the health care burden of types 1 and 2 diabetes and their complications, and the ideal goals of treatment. Each chapter would stand alone as an excellent course lecture for medical students, house staff or primary-care doctors. The rest of the book should aid physicians to reach the outlined goals.Much of the strength of the book comes from the outstanding contributors. Thus, the roles of autoimmunity and heredity in type 1 diabetes and of genetics and lifestyle in type 2 diabetes are clearly explained. The importance of defects in insulin-stimulated glucose uptake and β-cell failure in the etiology of type 2 diabetes are likewise elucidated. However, missing from the discussion on type 2 diabetes is the role of free fatty acids in the insulin resistance syndrome, specifically in dyslipidemia.The ‘how-to’ parts of the book are truly outstanding. Few textbooks on diabetes provide such detailed, sensible suggestions for managing the myriad problems associated with diabetes, from choice of oral agents in type 2 (a topic made far more complicated in the past several years with the release of new products including metformin and the thioglitazones) to initiation of insulin treatment. The education of medical students and house staff in diabetes often includes too much emphasis on the molecular biology of the diseases with insufficient attention to the practical aspects of getting a patient with diabetes into excellent control. This book is the antidote.The chapter on initiation of insulin therapy is extremely detailed. A medical student with no previous experience, and isolated on a desert island with only this book and insulin supplies, could initiate a reasonable program of insulin treatment for a patient with type 1 diabetes. Furthermore, this chapter would be a useful read for patients.The detailed ‘how-to’ chapters on nutritional and exercise counseling are unusual for a medical textbook, but are extremely helpful. It is also important for clinicians to help patients initiate an exercise program, because exercise counselors are frequently unavailable in the clinical setting, and physician advice has been shown to be effective, at least for women, in getting patients to exercise [1xEffects of physical activity counseling in primary care. The activity counseling trial: a randomized, controlled trial. The Writing Group for the Activity Counseling Trial Research Group. JAMA. 2001; 286: 677–687Crossref | PubMedSee all References[1]. Unfortunately, omitted from the discussion of exercise is the importance of screening individuals with coronary artery disease risk factors before they initiate an exercise program [2xExercise testing guidelines. Gibbons, R.J. et al. JACC. 1997; 30: 260–315Scopus (748)See all References[2].The encyclopedic coverage of diabetes complications and their management is always clear and easy to read. The usual topics of neuropathy, nephropathy, retinopathy and gasterointestinal complications are covered, in addition to the macrovascular risk factors, including dyslipidemia and hypertension. Polycystic ovary syndrome is given an excellent overview. One can hope that many studies completed since the writing of this text will be included in a revised edition.There are of course some drawbacks to any work of this expanse. There is some redundancy, but this is to be expected in a multi-authored book. Unfortunately the book went to press before the completion of the Diabetes Prevention Program, which showed that lifestyle changes in diet and exercise can prevent or delay the onset of type 2 diabetes by 58% (http://www.cdc.gov/diabetes/news/docs/dpp.htm). Several other ongoing trials in diabetes management are at least listed and described, leaving it to the reader to follow up for the results.This work provides something for every practitioner from the specialist to the medical student. For the endocrinologist or diabetologist, it is a fairly comprehensive summary of diabetes and related endocrine disorders. It is probably most useful, however, to the audience for which it was intended: doctors in training and clinicians. It should prove equally useful for those providing didactic teaching to medical trainees. I plan to keep it on my shelf and refer to it often.