book reviews
Diabetes and Cardiovascular
Disease
(Contemporary Cardiology.) Second edition. Edited by
Michael T. Johnstone and Aristidis Veves. 641 pp., illustrated.
Totowa, N.J., Humana Press, 2005. $145. ISBN 1-58829-413-7.
T iming is often everything. Certainly,
the second edition of Diabetes and Cardiovascu-
lar Disease could not have been published in a more
timely fashion, given that the worldwide inci-
dence and prevalence of diabetes are increasing
at an alarming pace. And as noted by the editors,
diabetes truly is a cardiovascular disease.
The concept that diabetes is a cardiovascular
disease is gradually being accepted; diabetes is
often referred to as a coronary-disease equivalent.
It is not possible for cardiologists and cardiovas-
cular surgeons to avoid treating patients with
diabetes. However, the fragmentation of patient
care has reached such proportions that cardiolo-
gists and cardiovascular surgeons often do not
manage the diabetic component of a patient’s ill-
ness nearly to the extent that would be of great-
est benefit to the patient. Books such as Diabetes
and Cardiovascular Disease provide a great resource
for readers needing to learn more about the re-
lationship between these disease entities.
This book is a serious attempt to provide a
comprehensive review of the basic and clinical
aspects of diabetes and the cardiovascular system.
Conveniently, the chapters are separated into two
parts — one part on the pathophysiology of dia-
betic cardiovascular disease and the other on clini-
cal aspects. Each chapter is written by highly re-
garded experts in their respective areas of focus,
and thus, the material is presented with clarity
and in detail. Both experimental and clinical data
are provided to characterize the role of diabetes
in producing vascular disease, including athero-
sclerosis and hypertension, heart disease (cardio-
myopathy, heart failure, and coronary syndromes),
and peripheral vascular disease. It is refreshing
that much attention is focused on the peripheral
vascular complications of diabetes, since they re-
sult in substantial morbidity and mortality.
Although “the metabolic syndrome” is discussed
at length in the book, little space is devoted to
the controversy surrounding this term. In fact, the
American Diabetes Association discourages its
use. I myself believe that the use of the term has
assisted the practicing primary care physician in
treating global risk in patients with this pheno-
n engl j med 354;10
The New England Journal of Medicine
Downloaded from nejm.org by Abdur Rahman on January 18, 2022. For personal use only. No other uses without permission.
Copyright © 2006 Massachusetts Medical Society. All rights reserved.
type, but its use does not add anything to the as-
sessment of global risk beyond what the individu-
al components of the syndrome delineate.
The book does not address the management
of diabetes in detail. In future editions, the edi-
tors might consider expanding the comprehensive
management of diabetes to include care by gen-
eralists and those in cardiovascular specialties,
since there will clearly not be enough “diabetolo-
gists” to care for the millions of patients with this
disorder. And greater participation in the care of
such patients by cardiologists and cardiovascu-
lar surgeons is needed.
This book is recommended for any serious
student of diabetes. In particular, cardiologists and
cardiology fellows, as well as cardiovascular sur-
geons and cardiovascular surgical fellows, should
be familiar with the material in it. It is also a valu-
able resource for those with more advanced knowl-
edge of diabetes, such as endocrinologists and
researchers active in the field of diabetes and car-
diovascular diseases. The reader must bring more
than a passing knowledge of diabetes to reading
this book in order to obtain the full benefit of
having such expert information compiled in one
source. This is not a book for the casual reader
or for someone wanting a quick, easy guide to
managing diabetes in practice.
Thomas D. Giles, M.D.
Louisiana State University School of Medicine
New Orleans, LA 70112
tgiles4@cox.net
Type 2 Diabetes, Pre-Diabetes,
and the Metabolic Syndrome:
The Primary Care Guide
to Diagnosis and Management
(Current Clinical Practice.) By Ronald A. Codario. 247 pp.
Totowa, N.J., Humana Press, 2005. $89.50.
ISBN 1-58829-471-4.
I have worked all my professional life
in a metabolic clinic. The referring doctors in
the community know what we do there, but our
patients are often confused. “Diabetes, and thy-
roid, you know,” make for a simpler explanation to
give to patients than going into detail about en-
docrinology and unusual hormones. The concept
of the metabolic syndrome is even less well un-
derstood by the public. The word “metabolic”
comes from the Greek word metabolikos, meaning
www.nejm.org march 9, 2006 1099
 The new england journal of medicine
“changeable” or “involving transition”; according
to modern medicine, metabolism is the process in
an organism by which nutritive material is built
up into living matter (anabolism) or broken down
into simpler substances (catabolism). The defini-
tion of the metabolic syndrome should therefore
be obvious to those of us who work in the field
of metabolism, but unfortunately, it is not. The
concept arose from a cardiologic, lipidologic, and
epidemiologic background, rather than from
among diabetologists, who remain skeptical of it.
In 2005, a joint statement by the American Dia-
betes Association and the European Association
for the Study of Diabetes called for a critical ap-
praisal of the syndrome: “Until much needed re-
search is completed, clinicians should evaluate and
treat all CVD [cardiovascular disease] risk factors
without regard to whether a patient meets the cri-
teria for diagnosis of the ‘metabolic syndrome’”
(Kahn R, et al. Diabetologia 2005;48:1684-99).
So what of Codario’s book on the subject? It
is certainly topical, and I suspect it will be bought
by doctors and nurses, as Neil S. Skolnik, the se-
ries editor, suggests in the introduction, “to up-
date and improve their knowledge in the field of
diabetes and the newly emerging science of the
metabolic syndrome.” It is not a textbook, al-
though it is well referenced to the recent litera-
ture. Instead, the book is a guide for the practicing
doctor whose informed patient has read some-
thing, or found something on the Web, about
this new disorder called the metabolic syndrome.
Such patients are very common in general prac-
tice; in the United States, according to the Third
National Health and Nutrition Examination Sur-
vey (1988–1994), the prevalence of the metabolic
syndrome among adults was 21 percent for the
whole population and rose to 43 percent among
those 60 years of age or older (Ford ES, et al.
Prevalence of the metabolic syndrome among U.S.
adults. JAMA 2002;287:356-9).
Edwin Gale, a professor of diabetic medicine
at the University of Bristol, in England, in a sa-
tirical editorial (Diabetologia 2005;48:1679-83) lik-
ens the search for a definition to a blind man’s
exploration of an elephant. But it is rather strange
that the currently widely used, though not iden-
tical, definitions come from the U.S. National
Heart, Lung, and Blood Institute, the American
Heart Association, and the National Cholesterol
Education Program’s Adult Treatment Panel. The
members of these organizations are not blind,
1100 n engl j med 354;10
The New England Journal of Medicine
Downloaded from nejm.org by Abdur Rahman on January 18, 2022. For personal use only. No other uses without permission.
Copyright © 2006 Massachusetts Medical Society. All rights reserved.
but they see things differently from the way dia-
betologists do.
Codario’s readers will find an educational com-
ponent in this book, either on the printed page
or in the value-added eBook/PDA that can be
downloaded from the accompanying CD-ROM.
The book is didactic, well laid out, and written
in short sentences, each containing one fact, which
is usually referenced. It focuses on all the points
raised by the experts who are trying to define
the metabolic syndrome, but it ignores the call
for a critical appraisal. The book certainly gives
a current answer to specific clinical questions
that will arrive in any consulting room. The title
starts with “type 2 diabetes” (although this, too,
has been difficult enough for diabetologists to
define) and includes a new term, “pre-diabetes.”
Were these two terms put into the title to attract
the reader? Pre-diabetes is not actually men-
tioned in the book, although the index lists im-
paired glucose tolerance — another problematic
term for the definition experts.
Perhaps the most important part of the title
is the subtitle, “the primary care guide to diagnosis
and management.” The book is exactly that, and,
with its engaging practicality and its focus on
day-to-day therapeutic problems (to say nothing
of the continuing medical education questions
that follow each chapter), it will provide a guide
for doctors and nurses meeting a patient who men-
tions the metabolic syndrome. These doctors may
well be cardiologists, lipidologists, or even epide-
miologists, but they still need to know what to
do, and this book will help. What Gerald Reaven,
professor emeritus of medicine at Stanford Univer-
sity (who is perhaps thankful that his name is no
longer attached to this conceptual can of worms),
makes of these new concepts is uncertain, although
he concludes in his own recent review of the evi-
dence, “the diagnosis of the metabolic syndrome
does not bring with it much in the way of patho-
physiologic understanding or clinical utility.”
Those of us on the front line of today’s clini-
cal practice will be happy to use this relatively
brief, authoritative, and clearly written book to
guide our medical decision making. No doubt, by
the time a definition of the metabolic syndrome
is agreed upon, the book will be out of date.
David R. Hadden, M.D.
Royal Victoria Hospital
Belfast BT12 6BA, United Kingdom
www.nejm.org march 9, 2006