Difficult DiabetesBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7299.1432 (Published 09 June 2001) Cite this as: BMJ 2001;322:1432
Eds Geoff Gill, John Pickup, Gareth Williams
Blackwell Science, £59.50, pp 320
ISBN 0 632 05324 0
Diabetes has scandalised me, scandalised and seduced in equal measure. The scandals have been the past lack of clinical trials with sensible outcome measures and the discrimination felt by people with diabetes from insurers, the Driver and Vehicle Licensing Authority, and employers. The seductions have been the nefarious clinical manifestations of diabetes and the complexity of understanding its pathophysiologies.
Since the publication of the Diabetes Control and Complication Trial and the United Kingdom Prospective Diabetes Study, we all feel more justified in chasing the holy grail of a low HbA1c—some patients more assiduously and more obsessively than their doctors. Can we do this more effectively and more safely?
The major problem in intensifying a treatment regimen in diabetes is that the risk of intrusive hypoglycaemia rises. Insulin replacement in patients with the absolute insulin deficiency of type 1 diabetes remains a challenge. Subcutaneous insulin therapy is often as elegant as an elephant trying to do ballet—there are frequent periods of hyperinsulinaemia and the risk of hypoglycaemia. Although diabetes teams are often enthusiasts about recommending multiple injection therapy to their patients, the evidence that this is superior is lacking if the criterion for success is HbA1c. Equivalent HbA1c results have been obtained in clinical trials comparing multiple injection therapy with twice daily biphasic insulin. Multiple injection therapy and insulin pump therapy, however, do have the potential to reduce the frequency of severe hypoglycaemia.
Treatment in type 2 diabetes is no less difficult—the options are broader and comorbidity is commoner. The shortest chapter in this book was also the most controversial and enjoyable. If you take a strictly evidence based approach to treating type 2 diabetes you should use only glibencamide (from the choice of sulphonylureas) and only metformin monotherapy in the subset of obese patients with type 2 diabetes. A stimulating read—be ready with your counter proposals.
Public health and media interest in the increasing prevalence of obesity continues unabated. It is still fab to be thin, while never before has obesity been a constant presence in our clinics. The concept of “diabesity” has changed some doctors' attitudes in the diabetes field. Should we concentrate on treating obesity and pay greater attention to the effect that diabetes treatments may have on obesity? There is growing evidence that treating obesity in patients with type 2 diabetes has measurable health benefits in terms of glucose control, blood pressure, and lipid profile, as well as self esteem. In terms of weight loss alone the most impressive results are from gastric surgery, although this is a treatment that has been less rigorously assessed. What is still unclear is whether the data from clinical trials will readily translate to a similar benefit in routine clinical practice.
The impact of diabetes on lifestyle has long been an interest of patients even if, at times, the medical profession has seemed less concerned. Driving with diabetes has been an area of vigorous campaigning by Diabetes UK, yet often little covered in medical education. The chapter on this gave an excellent overview of the poor evidence base used to discriminate against people with diabetes who wish to drive.
This multiauthor book, which has 17 chapters on many aspects of diabetes care, is mainly well written and topical. The chapter on erectile dysfunction will be especially valuable as a resource to some since it basks in the post-Viagra era. Diabetes physicians and diabetes specialist nurses will find this a reflective read capable of changing their attitudes and clinical practice.
KB has been reimbursed by Servier, manufacturer of gliclazide, and Roche, manufacturer of orlistat, for attending medical conferences. He has received a speaking fee from AstraZeneca, manufacturer of lisinopril.
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