The Many Faces and Facets of Dysglycemia

Like many other diseases, diabetes and its complications involve a spectrum of many different pathophysiologic factors that are often influenced by, and even blended with, genetic and environmental factors. Because diabetes affects people of all ages, it is further complicated by individual nuances not limited to those that are medical and psychosocial. In my short 27 years in private practice caring for people with many forms of diabetes, the most common forms of diabetes I have encountered mirror the most common forms of the disease: type 1 and type 2 diabetes. Approximately half of my practice comprises people with type 1 diabetes. However, these two forms of the disease are becoming increasingly difficult to distinguish from each other. This blending of disease types, along with the dissemination of new scientific information and the development of many effective medications and management-enhancing technology devices, have made the treatment of diabetes more complex but also much more rewarding than during my earlier days in practice, when fewer resources were available.

For these reasons, I was honored to be invited to read and review this book by Dr. Jay Shubrook, which delves into many of the current complexities of diabetes management. (By way of disclosure, it should be noted that both Dr. Shubrook and I currently serve as associate editors of Clinical Diabetes.)

It is well known that 85% of people with diabetes get their diabetes care from their primary care team. This book helps to clarify the complexities of modern diabetes management and impart knowledge to primary care providers that will enable them to better care for people with diabetes in real-world settings.

The book is divided into easy-to-read chapters that offer brief clinical vignettes highlighting the nuances of day-to-day care for a wide variety of people with diabetes. These case studies reveal true salient features we see in our clinics nearly every day. This approach offers an effective learning format that is more entertaining and engaging than traditional didactic teaching. Whether this book is read in one sitting or on an intermittent basis, each case study offers something practical that can be implemented in any busy clinic that serves people with diabetes.

The types of diabetes described include not only type 1 and type 2 diabetes, but also the less common forms, such as LADA (latent autoimmune diabetes of adulthood), monogenic MODY (maturity-onset diabetes of the young), secondary diabetes, ketosis-prone type 2 diabetes, and pregestational and gestational diabetes, as well as the rapidly expanding condition of prediabetes. Again, this wide spectrum of cases is likely to touch on nearly all of the patient presentations seen in both primary care and endocrinology practices. Throughout the multiple case studies, Dr. Shubrook describes and highlights key concepts regarding the many types of diabetes and how they differ with regard to diagnosis, genetics, clinical course, complications, and best management practices.

With regard to type 2 diabetes—by far the most common form—he explains the core concept that the disease is progressive and can be expected to require more intensive treatment over time. He also emphasizes the great importance of empowering people with type 2 diabetes to self-manage their condition to ensure the success of treatment over the long term. He discusses the differences between type 2 diabetes in youth (a growing problem) versus in adults with regard to risks for complications and treatment options and indications.

Dr. Shubrook impresses on readers the foremost importance of preventing diabetes and the closely associated condition of obesity through dietary and lifestyle interventions. He also describes the exciting possibility that early comprehensive management can bring about a remission of type 2 diabetes (i.e., a return to normal or near-normal glycemia). He also reminds readers that this eventuality is more likely than curing or reversing more long-standing diabetes and suggests ways to articulate this concept in discussions with people with diabetes.

I was particularly interested in and impressed by information Dr. Shubrook presents regarding a “step-down” versus the traditional “step-up” approach to therapy and its relationship to Dr. Ralph DeFronzo’s “treat to fail” characterization of traditional stepwise pharmacologic treatment of type 2 diabetes (1). This view represents an exciting and powerful paradigm shift for modern diabetes management.

Dr. Shubrook describes the psychosocial impacts of diabetes and how to address these on an individual basis. He explains the importance of psychological associations with diabetes, including depression and diabetes distress, explains their adverse effects on diabetes self-management, and offers helpful advice for treating these dangerous comorbidities.

As part of his comprehensive discussion of type 2 diabetes, Dr. Shubrook reviews the American Diabetes Association/European Association for the Study of Diabetes consensus algorithm for the management of hyperglycemia (2), the individualization of treatment goals based on age and comorbid risk factors (3), and the appropriate use of medications (4) and technology (5) to better serve people with diabetes and their health care professionals (HCPs) over the long term. Newer medications and more advanced technology have allowed for less aggressive insulin-based regimens overall for people with type 2 diabetes, leading to less hypoglycemia and weight gain; however, Dr. Shubrook cogently explains the powerful benefits of the appropriate and safe use of basal and bolus insulin therapy for those who do need it. He also describes key concepts for hypoglycemia prevention, including the use of more strategic fingerstick blood glucose testing, implementation of continuous glucose monitoring, and selection of medication combinations that do not increase the risk of hypoglycemia. He also offers a detailed review of current recommendations for and practical uses of noninsulin type 2 diabetes medications such as glucagon-like peptide 1 receptor agonists and sodium–glucose cotransporter 2 inhibitors, both of which provide extra-glycemic benefits including cardiovascular and renal protection.

Finally, Dr. Shubrook reviews the extensive proven benefits and appropriate use of diabetes self-management education and support, the practical importance of integrating family members into the diabetes care plan, and the value of pursuing a multidisciplinary team approach to diabetes care to ensure better long-term outcomes (6).

I highly recommend this book to any HCP who cares for people with diabetes. In an easy-to-read format, it covers the many types of diabetes seen in clinical practice and focuses on practical and common management issues, including offering advice about important interpersonal discussions between HCPs and their patients with diabetes. I am confident that it will be useful to any HCP with any level of diabetes knowledge, and especially family physicians, internists, other advanced practice HCPs, diabetologists, diabetes educators, dietitians, clinical pharmacists, medical residents, and even endocrinology fellows. I am humbled to say that this book has advanced my own knowledge further, allowing me to provide better care for people with diabetes.