(++++) SERIOUS APPROACHES TO A SERIOUS DISEASE

Conquer Your Diabetes: Prevention, Control, Remission. By Martin Abrahamson, M.D., and Sanjiv Chopra, M.D. Abrahamson Chopra Publishing. $24.95.

     The title of this knowledgeable, intelligent, clearly written book is a trifle misleading: one does not so much conquer diabetes as come to terms with it and learn to live with it – ameliorating its effects as much as possible. Certainly Harvard Medical School’s Martin Abrahamson and Sanjiv Chopra, who jointly direct the Division of Continuing Medical Education at Beth Israel Deaconess Medical Center in Boston, have the bona fides to instruct patients as well as doctors in what diabetes is all about, how to avoid it if possible, and how to cope with it if avoidance proves futile or is simply impossible.

     The book starts with patient-success stories, the underlying assertion being that “having a successful life with diabetes and not letting diabetes dictate” the terms of your life “takes work but is possible.” The authors mention patients they have known and also discuss a few celebrity cases of diabetes, trying to show readers that this disease – both Type 1 and Type 2 – can affect people of all sorts, from all walks of life, and in fact “has afflicted humans for thousands of years.” The terms diabetes comes from the ancient Greek word for “siphon” and refers to the way patients appeared to the Greeks to pass urine. Treatment was essentially nonexistent until the discovery of insulin, an event that led to the awarding of a Nobel Prize in Physiology or Medicine in 1923 – although insulin’s composition was not actually discovered until 1955 (research that resulted in another Nobel Prize award). The importance of insulin can scarcely be overstated, since diabetes, the authors explain, is the world’s most common metabolic disorder, affecting some 460 million people. Ninety-five percent of those people have Type 2 diabetes, for which insulin is helpful and sometimes necessary; the other 5% have Type 1, an autoimmune disease formerly called “juvenile diabetes” because of its typical early-in-life onset – and for Type 1, insulin is essential.

     Abrahamson and Chopra proceed methodically through their discussion of the history, effects and dangers of diabetes, noting that while Type 1 is not preventable, Type 2 can frequently be headed off through lifestyle modifications including weight loss, regular exercise, and dietary modification. “People who are motivated and can adhere to dietary modifications and an exercise regimen that leads to weight loss can prevent diabetes [from] developing indefinitely,” they assert – a statement that is scarcely new or surprising, but that is foundational to their presentation. Abrahamson and Chopra talk about clinical trials, medications, complications of the disease, cutting-edge research, and more. But again and again, they come back to variations on their basic recommendations regarding Type 2. In discussing prevention of nerve damage from diabetes, for instance, they call for “optimal control of blood glucose levels, smoking cessation, optimal control of blood pressure, optimal control of blood lipids,” and “optimal weight.” So patients cannot turn to Conquer Your Diabetes for easy or quick-fix solutions, many of which can be found in irresponsible corners of the Internet, relying on fad diets, “nutraceuticals” and other supplements, and no small dose of magical/wishful thinking.

     One difficulty for patients reading this book is that, in common with a great deal of modern medical writing, it makes clear how interconnected different body parts and the treatment of different conditions can be. This approach is actually a refreshingly holistic one within medicine, attempting to reconcile Western healthcare’s preoccupation with specific diseases and disease sites with the reality that no portion of the body can generally be treated without reference to other parts and, indeed, to the body as a whole. Unfortunately, the explanation of interconnectedness is likely to leave diabetes or prediabetes patients concerned that making one condition better can easily make others worse. For instance, regarding blood glucose levels, Abrahamson and Chopra point out that cholesterol-lowering, heart-protective statins can raise those levels – so how should patients feel about taking them? Abrahamson and Chopra mention a 2012 study saying that the benefits of statins outweigh the diabetes hazard, but that decade-old research is all that they cite, and readers are likely to be left worrying that caring for their heart may raise their diabetes risk. Antipsychotic medicines are also associated with diabetes, Abrahamson and Chopra point out, adding, however, that the drugs “should be continued if appropriate.” Similarly, thiazides (used for hypertension) may raise glucose levels, especially in higher doses. Nothing Abrahamson and Chopra say about these medicines is incorrect, but their scientific detachment in explaining the issues will do little to reassure worried patients who may have diabetes plus one or more comorbidities, or may be under treatment for other conditions and are now worried about adding diabetes to the list.

     The recommendations in Conquer Your Diabetes are unexceptionable and presented clearly and soberly. “Choose a diet that you will be able to adhere to long-term,” Abrahamson and Chopra write, “and enjoy the ritual of sharing food with family or friends.” And “seek the advice of a nutritionist for nutrition counseling.” Fine ideas, these, and certainly helpful for heading off diabetes or controlling it. Now, in the real world, what is the insurance coverage for nutrition counseling? How can careful attention to the specifics of the Mediterranean diet be reconciled with people’s income levels? With their work schedules? With their children’s and families’ nutritional needs? With their time and location constraints? These are the sorts of questions that will immediately occur to many readers – in some cases because of a lack of desire to change ingrained habits, but in others because these real-world concerns really do stand in the way of adopting the sensible approaches outlined by Abrahamson and Chopra.

     What is missing in Conquer Your Diabetes is attention to the psychological barriers to adoption of the authors’ approach. Abrahamson and Chopra are clinicians and clinical instructors, not psychotherapists, and within their field of expertise, what they have to say is to the point, carefully researched, and presented forthrightly. To them, with their experience, much of what they recommend is self-evident, or would be if people only had the necessary information – which Conquer Your Diabetes exists to provide. But even people who learn what is best for their health often face substantial barriers, from external circumstances to internal psychological issues, that make it hard (if not impossible) to do what doctors such as Abrahamson and Chopra know it is best to do. Conquer Your Diabetes is packed with important, highly useful information presented in a direct manner with a strong appeal to readers’ brains. But one part of holistic medicine involves realizing that clinicians must win over patients’ hearts and minds in order to gain acceptance of recommendations that many people, rightly or wrongly, find very difficult to follow. Conquer Your Diabetes is a first-rate guide for people already committed to the “takes work but is possible” notion of controlling the disease. What it does not do, what it is not equipped to do, is to instill that commitment in readers who are not already in possession of it.