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Sansum Diabetes Research Institute
2219 Bath Street
Santa Barbara, CA 93105
E-mail: ljovanovic{at}sansum.org
Before the advent of insulin therapy, persons with diabetes wasted away to skin and bones and died of malnutrition. The classic symptoms of polydipsia, polyphagia, and polyuria were all the result of severe hyperglycemia that was incompatible with life. Life could be sustained for only a few days or weeks longer when the diet was restricted to pure fat, which minimized the sugar consumed or that appearing in the bloodstream from any dietary ingestion of carbohydrates or glucogenic amino acids in proteins. Death was also the result of severe acidosis from lack of insulin, which led to the conversion of the free fatty acids into ketones. The discovery of insulin and the worldwide commercialization of insulin by 1926 essentially converted diabetes from a disease that killed acutely to a chronic disease that killed every organ in the body but did so slowly. Answers to the major questions about the pathophysiology, prevention, and treatment of diabetes-related complications have been the "Holy Grail" of diabetes research for the past 80 y.
Nutrition as a cause and a treatment of diabetes and its precursor, the metabolic syndrome, has now received the emphasis that it deserves. The book entitled Nutrition and Diabetes: Pathophysiology and Management, edited by Emmanuel Opara, is a major contribution to our forward thinking about nutrition and diabetes in general and especially to our thinking about the role of nutrition in the pathophysiology of the disease and about strategies that may direct the clinician in management.
This book is written from the premise that most persons afflicted with diabetes worldwide have type 2 diabetes, and thus it is largely devoted to a discussion of type 2 diabetes and its presumed precursors of overnutrition and resulting obesity. This emphasis on type 2 diabetes is not specified in some of the chapters, and the nutritional management of type 1 and type 2 diabetes is described as though the 2 types are equivalent. This shortcoming is minimized if the reader merely accepts that the book is written about type 2 diabetes (except for the 2 chapters on type 1 diabetes), and thus all references to nutritional therapy for diabetes relate to type 2 diabetes.
The chapters on obesity are the "true gold" of the book. The entire first section is devoted to obesity, and the rest of the book is built on the foundation laid in that section. The last section, on oxidative stress, is excellent on its own, but nutrition seems to be lost in much of the discussion. However, the chapters devoted to diabetes-related complications are weak from a nutritional perspective. Even in the chapter on gastroparesis, the section on dietary management does not provide the real "how-to" needed to treat this difficult condition. In addition, the debate about the role of carbohydrate concentration in the meal plan was minimized throughout the book; in fact, the concept of matching the preprandial doses of insulin to the carbohydrate content of the meal was ignored completely. Only one page is devoted to insulin therapy in type 2 diabetes, and the matching of insulin to the meal is not mentioned. In light of the hyperglycemia that occurs after a high-carbohydrate-content meal, treatment to prevent postprandial hyperglycemia should be stressed. The chapter on Web-based simulations of dynamic variations in the treatment of type 1 diabetes points out that the carbohydrate content of a meal must be included in an algorithm for insulin delivery. However, other than a recommendation to download the computer program to understand the relation between the insulin dosage and the meal-plan, the chapter did not facilitate patient care. The chapter on diabetes and pregnancy did not emphasize nutrition for the diabetic pregnant woman. In fact, medical nutritional therapy is mentioned in only one sentence, in the section on management of gestational diabetes. The reference list is devoid of articles on nutrition in pregnancy, and no nutritional management is offered for obese pregnant women or women with type 1 or type 2 diabetes. In essence, the chapter on diabetes and pregnancy is devoted to the obstetrical management of women with diabetes, and this topic is covered well.
We have entered a new era in our understanding of the pathophysiology and thus the optimal treatment of obesity, the metabolic syndrome, type 2 diabetes, and the resultant complications of diabetes, in which treatment is not optimized to normalize metabolism. Nutritional management played the major role in treatment before the discovery of insulin. Now, 80 y after insulin became commercially available worldwide, nutritional management continues to be the cornerstone of therapy. This volume beautifully sets up the paradigm for the importance of nutrition in the pathophysiology of diabetes, and thus the book can be used to facilitate research into the optimal medical nutritional prescriptions to prevent and treat diabetes. Although the book does not provide the needed management strategies, we look forward to a sequel that can give us the prescriptions for success.