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The Uncomplicated Guide to Diabetes Complications
Edited by Marvin E. Levin, M.D. and Michael A. Pfeifer, M.D.
American Diabetes Association Inc.
374 pp $18.95

When I think of the complications that can arise with diabetes, a parade of people files past in my mind's eye: a woman with a scar on her chest from coronary artery bypass surgery, a man unbuckling his plastic leg so I can check how his stump is healing, a row of patients on dialysis.

Mention of the acute complication "diabetic ketoacidosis" conjures up a teenager I cared for while working in a jail ward as a student 20 years ago. When he was arrested, he did not have his insulin, so his blood glucose shot up, altering his blood chemistry. He became severely dehydrated.

I spent all of one long night with him, drawing his blood every hour, running the tests for glucose, sodium, and potassium myself on an old machine I had been taught to use that evening. I would report the results to my resident, and he would tell me what quantities of insulin and fluids to order. By the time I had completed my circuit, it was almost time to start over again. That night I was swept into my patient's own private diabetes. I felt his pulse calm and his skin plump under my fingers.

There may be 20.8 million Americans with diabetes, but for each person, it is a private illness with a unique course. A comprehensive guide to its potential pitfalls, The Uncomplicated Guide to Diabetes Complications is like a road map with every pothole marked. No driver would hit every pothole, even without the map. With it, more of them can be avoided.

The editors, physicians Marvin E. Levin and Michael A. Pfeifer, chose a different expert to write each chapter of the guide. The book is unified by the question-and-answer format every author follows. (It's not essential, but I would have appreciated a few sentences of biography for each contributor, rather than a simple list of their degrees. Was that a PhD in English or biology?)

Many of the authors include case studies of individuals with specific complications. These techniques help break down the difficult, but necessary, discussions of physiology. Since glucose is the energy coin of the body's economy, it is involved in every transaction. A person without diabetes can be like a child, unconscious of metabolic costs, because there are so many automatic mechanisms to keep blood glucose normal. Someone managing diabetes is a grownup on a budget, constantly balancing eating, which increases glucose, against exercise and medication, which decrease it.

As Richard Rubin writes in the chapter called Psychological Complications, "diabetes can be a heck of a disease. Even if your blood glucose control is good and you haven't developed any long-term complications, living with diabetes is no fun." The editors chose to place this chapter sixteenth, but I would suggest reading it first. The adjustment to a chronic disease that requires attention 24 hours a day, seven days a week is one of the toughest transitions a person can face. The excellent information in the chapters about stroke, cholesterol, the heart, and the kidneys is useless to someone who is too discouraged to make an appointment with the eye doctor, too fearful to inject insulin, or too depressed to imagine his or her life in 20 years.

It is always a challenge to discuss Type 1 and Type 2 diabetes in one volume. If doctors had known long ago what we know now, they would have chosen different names for the two illnesses: insulin deficiency and insulin resistance. The treatment for insulin deficiency is and has always been insulin. Medications for insulin resistance seem to change every year, so be sure to ask your doctor if your prescription is up-to-date. Since this book was published, for example, one of the medications discussed, Rezulin, has been taken off the market. Another important point is that insulin resistance can be delayed or prevented by increased physical activity and a healthy diet. Insulin deficiency, on the other hand, isn't preventable as far as we know.

The course of diabetes in any given individual is highly variable, which is why it took many years to prove that blood glucose control could prevent or delay late complications. Even with the best control, most people develop some neuropathy in the form of pain or numbness after 10 years. After 20 years, many have lost some sight due to retinopathy. The authors make the important point that there are still ways to prevent further damage once problems arise. With vigilance, a numb foot will not develop a severe ulcer, and laser treatments can prevent mild vision loss from progressing to blindness. It is important to monitor other common health problems like high blood pressure as well, since every risk factor accelerates arteriosclerosis.

At my branch of the public library, there are more books about cancer than about diabetes, which is ironic, given how much control people can have over the course of diabetes compared to cancer. A diagnosis of cancer stops people in their tracks; whatever treatment they undergo, they are constantly re-evaluating their situation. Too often, however, people with diabetes learn there is a pill to treat it and give it no further thought. Every person with diabetes should read this book through to understand the scope of the possibilities, then keep it close for reference. After all, it's your vision, your heart, your brain -- your own private diabetes.

-- Toni Martin, MD, is an internist, geriatrician, and author who lives in Oakland, California. The former head of patient education at Kaiser Permanente, Martin was a regular contributor to the late Hippocrates magazine and is the author of the book How to Survive Medical School.

References

First published January 22, 2001
Last updated February 11, 2008
Copyright © 2001 Consumer Health Interactive

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