Yes, my wife, Lisa thinks I am crazy and she may have a valid point. Nevertheless, the importance of my decision to write the 3rd edition of my medical textbook Diabetes Management in Primary Care was based on providing better care for my own patients. Really? How can writing a 700 page book help you, my patients?

Writing a medical text book is no easy task. Unlike writing a fictional novel, the text book must be provide accurate information while providing guidance to physicians on how best to manage a chronic, progressive disease state. The vast majority of primary care providers are unaware or disagree with the treatment guidelines published by several professional societies including  the American Diabetes Association, American Association of Clinical Endocrinologists and International Diabetes Federation.  Family doctors argue that every patient with diabetes is unique in that we care for newborns, pregnant women, adolescents, nursing home patients, people with drug dependency and hospitalized patients. Therefore, guidelines cannot and should not be applied to people of all ages, races, genders, activity levels or even political parties! Clinicians need to customize care, but to do so we need to understand the pathogenesis and science behind the disease we are treating.

The field of diabetes is constantly changing. Very little of what was published in the 2nd Edition of Diabetes Management in Primary Care (2012) is up to date. For example, we used to believe that type 2 diabetes was the result of 8 different deficiencies leading to elevated blood glucose levels. The core defects of type 2 diabetes remain loss of insulin secretion from the pancreas and increased insulin resistance as the skeletal muscles fail to absorb glucose while the liver tends to produce excessive amounts of sugar into the blood stream. We  now know that the brain, kidneys, fat cells, gut and pancreas all play an important role in glucose dysregulation. I believe that there could be as many as 24 reasons that patients develop type 2 diabetes, some of which include low testosterone, low iron, and chronic inflammation. For type 1 diabetes, research is looking into abnormalities of the gut bacterial content. Perhaps replacing the “bad” bacteria with “good” bacteria could potentially reverse type 1 diabetes? We are working on this. Stay tuned…

Over the past year we have seen the approval of several new oral agents and insulins, some of which were studied at our very own research center in Chino! Within the next 5 years we will have combinations of insulins plus GLP-1 receptor agonists which will lower the A1C of patients by 2.6 %. We may also have “smart insulins” which work only when blood glucose levels are high. Expect to stop checking your blood sugars as “ambulatory blood glucose monitoring” is approved by the FDA. These small sensors worn on the arm for 2 weeks do not require calibration and can read blood sugars every 15 minutes. They will be read and recorded by a hand held scanner. We will also have new insulin pumps including disposable pumps which can be worn for 3 days and trashed.

One advantage of writing a medical text book is that I will have access to some of the best scientific minds in the world. Once each chapter is written, a process which may take 30 days, the manuscript is submitted for peer review. These experts will dissect my words of wisdom to make certain that my work is accurate and useful. I will also be discussing some of the more difficult aspects of diabetes management with the experts. The new book will include chapters on addiction, obesity and disease prevention, which will require considerable thought and reflection.

I anticipate that this book will take 13 months to write. Fortunately, I have a copy editor, Debbie Kendall, who works for the American Diabetes Association. Debbie will help me formulate and organize my manuscripts. She does all the hard work. All I have to do is think!

When all is said and done I believe my knowledge of diabetes will surpass that of any other primary care physician in the country. I felt this way after publishing each of the first two editions of the book and look forward to finishing the next chapter in my literary career. Upon completion of the 2nd edition, the American Association of Clinical Endocrinologist presented me with a fellowship degree. I am the only family physician in the country to have been awarded this honor.

You may notice me getting a little smarter over the next few months. That’s OK. I am writing this book to stay up on the field of diabetes. There is so much to learn and so many people to help. We are all in this together.

Thanks for your support.


Dr. Unger