Book Review

Diabetes: Current perspectives

N Engl J Med 2000; 342:1533May 18, 2000

Article

Diabetes: Current perspectives
Edited by D. John Betteridge. 359 pp., illustrated. London, Martin Dunitz, 2000. $99.95. ISBN: 1-85317-555-2

Diabetes mellitus is becoming one of the most important health problems not only in developed countries but also in developing countries. Worldwide, more than 140 million people are estimated to have diabetes, and projections indicate that there will be over 230 million people with diabetes by the year 2010. More than half of this population will be in Asia, because of the overall increase in population and the rapidly increasing prevalence of diabetes in this region. Because of the high morbidity and mortality associated with complications of diabetes, such as renal, retinal, and vascular diseases, diabetes mellitus is a burden on both patients and society. Primary prevention of the disease and the prevention of diabetic complications are of great practical importance.

Diabetes: Current Perspectives focuses on these issues. Chapter 1 discusses the remarkable increase in the direct and indirect costs of care for patients with diabetes in the past decade. Although a projection of these costs has not been done, they will become enormous. The prevention of diabetes mellitus is therefore an urgent issue all over the world.

For effective primary prevention, the causes and mechanisms of the disease must be understood. There are two major types of diabetes mellitus: type 1 and type 2. Both are based on genetic predispositions that are quite complex, as discussed in chapter 2. Progress in the Human Genome Project and many other genetic studies will certainly help elucidate the multiple genes involved in type 1 and type 2 diabetes mellitus.

Type 1 diabetes is caused by autoimmune destruction of pancreatic islets; this immunologic process seems to be genetically determined, at least in part. Since autoantibodies against islets or insulin can be detected in the prediabetic stage and some predisposing genetic factors — such as certain HLA alleles — are known, immunologic interventions to prevent type 1 diabetes are of great interest. As discussed in chapter 3, the results of trials of preventive strategies are far from conclusive, but they do suggest the potential usefulness of immunologic intervention.

Type 2 diabetes, which is more prevalent than type 1, is a multifactorial disease. The genetic basis of type 2 diabetes is complex, and so far it is understood only in a subtype of diabetes known as maturity-onset diabetes of the young, which is caused by a single gene defect. By contrast, most cases of type 2 diabetes appear to be polygenic in origin. Moreover, insulin resistance caused by factors such as obesity and aging is an important precipitating factor for diabetic states. Clarifying the pathophysiology of impaired glucose tolerance and the development of type 2 diabetes is an important aim of this book.

A major theme of this book, however, is the pathogenesis of diabetic complications. Since the Diabetes Control and Complications Trial demonstrated that intensive glycemic control reduced the risk of disease-related complications in patients with type 1 diabetes and since similar, though less conclusive, results were obtained in studies of patients with type 2 diabetes, it has been generally accepted that hyperglycemia is the main cause of these complications. However, the way in which glucose exerts toxic actions on blood vessels and other tissues has not been established. Possible mechanisms of glucose-induced toxicity are reviewed in several chapters in this book.

The goal of therapy for diabetes is to normalize blood glucose levels, thereby optimizing blood lipoprotein levels and preventing complications. To achieve this goal, new therapeutic agents have been identified. One is a group of rapid-acting insulin analogues that, once administered, reach levels that mimic postprandial plasma insulin levels in normal subjects and to prevent high blood glucose levels after a meal. In addition, new oral agents can reduce insulin resistance, a characteristic feature of type 2 diabetes. These advances are discussed extensively in this book. Another important issue in management is helping patients develop the proper knowledge, skills, and attitudes, because effective self-care is indispensable for the treatment of lifelong diseases such as diabetes mellitus.

Although there have been many good books on diabetes, Diabetes: Current Perspectives is a concise book focusing on subjects of practical importance. It does not deal thoroughly with basic mechanisms of the control of glucose metabolism, insulin secretion, and insulin action. Most of the chapters are well written and fully referenced.

Hiroo Imura, M.D.
Kobe City General Hospital, Kobe 650-0046, Japan