Book Review

Medical Management of Diabetes Mellitus

N Engl J Med 2000; 343:516August 17, 2000

Article

Medical Management of Diabetes Mellitus
Edited by Jack L. Leahy, Nathaniel G. Clark, and William T. Cefalu. 761 pp. New York, Marcel Dekker, 2000. $99.75. ISBN: 0-8247-8857-5

More than 150 million people in the world have diabetes, the prevalence of which is increasing so rapidly that the management of diabetes is a priority in all branches of medicine. The new therapies and rapidly evolving evidence are making us all reevaluate our practice. We can no longer be one-dimensional “sugar doctors” but, instead, must address the three dimensions of cardiovascular risk prevention: glycemia, lipid levels, and blood pressure.

In addition to knowing the evidence, we all need practical advice. The detached reviewer can point to the inadequate number of randomized controlled studies of the treatment of diabetic ketoacidosis, but this is of little help to the clinician in the emergency room. When facing difficult clinical situations, we turn to wiser, more experienced colleagues. These experts use both personal experience and the evidence base to provide the best care for patients.

Leahy and his colleagues go a long way toward achieving their aim of writing a how-to manual for the care of patients with diabetes. They have commissioned experts to write chapters on clinical topics. The result is a book that is not intended to be encyclopedic but that focuses on practical advice. It is good to see that the chapter authors commit themselves to particular regimens and use such phrases as “we have found this approach useful.” Many of the chapters have been written with the clarity of thought that typifies the wise clinician. There are some jewels; for example, reading Maryniuk's chapter on medical nutritional therapy was like being at an inspired educational session that leaves you knowing that you need to change your practice.

Inevitably, there is a considerable delay in publishing a multiauthored textbook, and changes in management during the past 18 months are not included in this book. In 2000 it seems surprising that the book does not cover in detail the use of insulin–glucose infusions in acute myocardial infarction or islet-cell transplantation.

At times the editor's pen has been too lenient; one suspects series editor, Burton Sobel, was proposing optimal treatment for diabetes, not “optical” treatment. The style used to cite references differs from one chapter to another. In addition, there is little cross-referencing of information between chapters. In some cases, different opinions are offered about a topic discussed in two different chapters (e.g., the best therapy for diabetic gastroparesis). This, however, reflects the reality of clinical practice.

There is an inevitable North American bias to this book. European readers will therefore have to remember their 18-times table to convert the glucose values in this book into millimoles per liter. Other transatlantic differences include the fact that metformin has been available in Europe for decades. In the United Kingdom Prospective Diabetes Study, it was effective in both controlling glycemia and preventing complications in obese patients. In the United Kingdom, we would consider metformin, with its anorectic properties, the clear treatment of choice in overweight patients.

Many of my minor quibbles result from the style of the book, which emphasizes opinions. It is always easier to disagree with opinions than with matters of fact. There will never be a randomized, controlled trial that addresses every clinical situation, so we will always need the wisdom of experienced clinicians, extrapolating from what evidence there is. This book goes a long way toward providing the distilled wisdom of the North American diabetes community, and we can all learn from it.

Andrew T. Hattersley, D.M.
Royal Devon and Exeter Hospital, Exeter EX2 5AX, United Kingdom