Introduction The last three decades of the 20th century witnessed a spectacular and remarkable progression in the delivery of diabetes care. In the 1970s diabetes provision was almost entirely hospital-based but by the millennium the exponential explosion of diabetes numbers necessitated a complete restructuring of diabetes services with a substantial switch to primary care, while hospital diabetes centres focused on more specific specialist and complicated subgroups. This period of time saw a radical transformation of diabetes management from an historical empirical, rigid conformity, overtly didactic and prescriptive in nature, to the guiding principle of a much more patient-centered and flexible approach. In this time, we witnessed dramatic developments with insulin and its usage – new insulins, new delivery devices – and once the importance of good diabetes control was fully accepted and the rational evidence base established, the monitoring of such metamorphosed from indirect and generally inadequate urinalysis to the increasingly sophisticated measurement of blood glucose, both immediate and long-term. With these transformative developments, education for healthcare professionals, and for people living with diabetes, became a prime priority to be integrated into the singularly rewarding domain of diabetes care.
{"title":"Insulin: a momentous transformation of diabetes care from the 1970s to the millennium","authors":"K. Shaw","doi":"10.15277/bjd.2022.355","DOIUrl":"https://doi.org/10.15277/bjd.2022.355","url":null,"abstract":"Introduction The last three decades of the 20th century witnessed a spectacular and remarkable progression in the delivery of diabetes care. In the 1970s diabetes provision was almost entirely hospital-based but by the millennium the exponential explosion of diabetes numbers necessitated a complete restructuring of diabetes services with a substantial switch to primary care, while hospital diabetes centres focused on more specific specialist and complicated subgroups. This period of time saw a radical transformation of diabetes management from an historical empirical, rigid conformity, overtly didactic and prescriptive in nature, to the guiding principle of a much more patient-centered and flexible approach. In this time, we witnessed dramatic developments with insulin and its usage – new insulins, new delivery devices – and once the importance of good diabetes control was fully accepted and the rational evidence base established, the monitoring of such metamorphosed from indirect and generally inadequate urinalysis to the increasingly sophisticated measurement of blood glucose, both immediate and long-term. With these transformative developments, education for healthcare professionals, and for people living with diabetes, became a prime priority to be integrated into the singularly rewarding domain of diabetes care.","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":"1 1","pages":""},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67138926","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
This year we celebrate the centenary of the discovery of insulin, when researchers at the University of Toronto successfully treated the first individual with T1DM. It was undoubtedly a major breakthrough. Insulin transformed children and adults destined to die within 2-3 years into healthy individuals within a few weeks and many went on to live full and productive lives. Yet the optimism that the ready availability of insulin would result in a cure for a previously fatal disease was gradually replaced by a realisation that insulin was not a panacea. Over the years that followed, many of those on treatment developed serious microvascular complications resulting in blindness, amputation and renal failure. It gradually became clear that keeping glucose levels close to normal was key. But since blood glucose had to be measured in hospital labs and those with diabetes were only able to measure glucose in their urine the challenges of keeping levels at target were immense. Episodes of severe hypoglycaemia were common, and many authorities considered it too dangerous to attempt to keep glucose at near-normal levels. With the advent of glucose monitoring in the late 1970s, pioneers such as Berger and Mühlhauser realised that this revolutionary technology could be used by patients at home to enable them to manage their diabetes themselves. Positive trial results were ignored by many healthcare professionals and it took another 30 years for the UK diabetes establishment to adopt this approach. In this chapter I describe how structured education in diabetes was developed, the evidence for its effectiveness and the remaining challenges which still need to be overcome. Following the discovery of insulin, most healthcare professionals were slow to realise that it is the person with diabetes (or their family) who holds the key to implementing effective self-management. Yet there were some professionals around the world who grasped this. Perhaps the first was Elliot Joslin, who was working in Boston when insulin was discovered. He realised rapidly that for treatment to work properly the patients had to be trained to be their own doctors and had to learn to adjust insulin themselves. He wrote a manual for patients in the early 1920s and, in a paper he wrote in 1946, he reflected that any insulin therapy was "a waste of time and money unless the patient was thoroughly instructed to manage his own case”.1 Karl Stolte, a paediatrician working in Rostock in Germany, argued in 1929 that children should be allowed to eat freely with insulin adjusted according to the amount of glucose in their urine.2 It appears this was too much for the medical mainstream in Germany at that time and his insights went unheeded. Some British physicians did grasp the importance of self-management. RD Lawrence, whose own life was saved by the discovery of insulin, became head of the diabetes department at King’s College Hospital and by 1929 had written two books, “The Diabetic Life” and “
{"title":"Handing control to the patient - structured education in diabetes","authors":"S. Heller","doi":"10.15277/bjd.2022.363","DOIUrl":"https://doi.org/10.15277/bjd.2022.363","url":null,"abstract":"This year we celebrate the centenary of the discovery of insulin, when researchers at the University of Toronto successfully treated the first individual with T1DM. It was undoubtedly a major breakthrough. Insulin transformed children and adults destined to die within 2-3 years into healthy individuals within a few weeks and many went on to live full and productive lives. Yet the optimism that the ready availability of insulin would result in a cure for a previously fatal disease was gradually replaced by a realisation that insulin was not a panacea. Over the years that followed, many of those on treatment developed serious microvascular complications resulting in blindness, amputation and renal failure. It gradually became clear that keeping glucose levels close to normal was key. But since blood glucose had to be measured in hospital labs and those with diabetes were only able to measure glucose in their urine the challenges of keeping levels at target were immense. Episodes of severe hypoglycaemia were common, and many authorities considered it too dangerous to attempt to keep glucose at near-normal levels. With the advent of glucose monitoring in the late 1970s, pioneers such as Berger and Mühlhauser realised that this revolutionary technology could be used by patients at home to enable them to manage their diabetes themselves. Positive trial results were ignored by many healthcare professionals and it took another 30 years for the UK diabetes establishment to adopt this approach. In this chapter I describe how structured education in diabetes was developed, the evidence for its effectiveness and the remaining challenges which still need to be overcome. Following the discovery of insulin, most healthcare professionals were slow to realise that it is the person with diabetes (or their family) who holds the key to implementing effective self-management. Yet there were some professionals around the world who grasped this. Perhaps the first was Elliot Joslin, who was working in Boston when insulin was discovered. He realised rapidly that for treatment to work properly the patients had to be trained to be their own doctors and had to learn to adjust insulin themselves. He wrote a manual for patients in the early 1920s and, in a paper he wrote in 1946, he reflected that any insulin therapy was \"a waste of time and money unless the patient was thoroughly instructed to manage his own case”.1 Karl Stolte, a paediatrician working in Rostock in Germany, argued in 1929 that children should be allowed to eat freely with insulin adjusted according to the amount of glucose in their urine.2 It appears this was too much for the medical mainstream in Germany at that time and his insights went unheeded. Some British physicians did grasp the importance of self-management. RD Lawrence, whose own life was saved by the discovery of insulin, became head of the diabetes department at King’s College Hospital and by 1929 had written two books, “The Diabetic Life” and “","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":" ","pages":""},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49224620","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Who would have thought? Surgery as a ‘cure for type 2 diabetes (T2DM)’. I would like to introduce one of my patients, Sarah, a 46year-old woman. She presented 10 years ago, living with obesity (BMI 44) and poorly controlled T2DM. She had been taking insulin for eight years, plus additional GLP-1 agonists and metformin. She underwent several lifestyle interventions for weight loss with little success. She subsequently underwent a Roux-en-Y gastric bypass (RYGB) and was able to come off all insulin and oral antiglycaemic medications. She only takes the recommended multivitamin replacement post-bariatric surgery now. Her HbA1c has been well controlled for several years.
{"title":"Fat: bariatric surgery and procedures","authors":"B. McGowan","doi":"10.15277/bjd.2022.368","DOIUrl":"https://doi.org/10.15277/bjd.2022.368","url":null,"abstract":"Who would have thought? Surgery as a ‘cure for type 2 diabetes (T2DM)’. I would like to introduce one of my patients, Sarah, a 46year-old woman. She presented 10 years ago, living with obesity (BMI 44) and poorly controlled T2DM. She had been taking insulin for eight years, plus additional GLP-1 agonists and metformin. She underwent several lifestyle interventions for weight loss with little success. She subsequently underwent a Roux-en-Y gastric bypass (RYGB) and was able to come off all insulin and oral antiglycaemic medications. She only takes the recommended multivitamin replacement post-bariatric surgery now. Her HbA1c has been well controlled for several years.","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":" ","pages":""},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48510908","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A pancreatic extract which was successful in lowering glucose in diabetes was developed and commercialized with leader-ship from the University of Toronto in 1921-1922. The active principle remained unknown, though it was assumed to be the ‘insulin’ (or ‘isletin’ or ‘insuline’) identified microscopically in the islets of Langerhans from work in the previous 50 years. Within four years the active principle was crystallized by Abel and co-workers, and convincing proof given that it was a peptide. Determining the amino acid sequence of this relatively small protein proved a 30-year task for science, due to the confounding effects of two short chains united by di-sulphide bridges. Even then it was a mystery how the sequence related to insulin activity. That remained the case when the early X-ray diffraction work in the 1930s by Crowfoot (Hodgkin) matured in 1969 with the determination of the 3-dimensional structure of the insulin hexamer. Meanwhile 25 years of work, much in industry, invented useful extended-acting insulin preparations and, over an even longer time course, insulin preparations of high enough purity to be non-immunogenic in clinical practice. In the 1960s and 1970s work on radioimmunoassay and on glucose clamps provided tools that would prove critical to the further development of insulin as a medication over its second 50 years.
{"title":"From muck to molecule: insulin discovery over 50 years","authors":"Philip Home","doi":"10.15277/bjd.2022.354","DOIUrl":"https://doi.org/10.15277/bjd.2022.354","url":null,"abstract":"A pancreatic extract which was successful in lowering glucose in diabetes was developed and commercialized with leader-ship from the University of Toronto in 1921-1922. The active principle remained unknown, though it was assumed to be the ‘insulin’ (or ‘isletin’ or ‘insuline’) identified microscopically in the islets of Langerhans from work in the previous 50 years. Within four years the active principle was crystallized by Abel and co-workers, and convincing proof given that it was a peptide. Determining the amino acid sequence of this relatively small protein proved a 30-year task for science, due to the confounding effects of two short chains united by di-sulphide bridges. Even then it was a mystery how the sequence related to insulin activity. That remained the case when the early X-ray diffraction work in the 1930s by Crowfoot (Hodgkin) matured in 1969 with the determination of the 3-dimensional structure of the insulin hexamer. Meanwhile 25 years of work, much in industry, invented useful extended-acting insulin preparations and, over an even longer time course, insulin preparations of high enough purity to be non-immunogenic in clinical practice. In the 1960s and 1970s work on radioimmunoassay and on glucose clamps provided tools that would prove critical to the further development of insulin as a medication over its second 50 years.","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":" ","pages":""},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42956161","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
This article was written as a contribution to mark the centenary of the first administration of insulin to a human in 1922. Writing from an Aberdeen perspective, an introductory passage will place emphasis on the role of JJR MacLeod, under whose supervision the discovery of insulin by Banting and Best was made. The major thrust of the article, however, will be on the cloning and sequencing of the human insulin gene, and the impact it had on the scientific career of the author. It initiated a journey to find alternative therapies for diabetes that led sequentially though gene therapy, embryonic stem cell-derived islets, and reprogramming. Our experience in these areas will be described, with emphasis on the strengths and weaknesses of each of these approaches.
{"title":"journey from the insulin gene to reprogramming pancreatic tissue","authors":"K. Docherty","doi":"10.15277/bjd.2022.371","DOIUrl":"https://doi.org/10.15277/bjd.2022.371","url":null,"abstract":"This article was written as a contribution to mark the centenary of the first administration of insulin to a human in 1922. Writing from an Aberdeen perspective, an introductory passage will place emphasis on the role of JJR MacLeod, under whose supervision the discovery of insulin by Banting and Best was made. The major thrust of the article, however, will be on the cloning and sequencing of the human insulin gene, and the impact it had on the scientific career of the author. It initiated a journey to find alternative therapies for diabetes that led sequentially though gene therapy, embryonic stem cell-derived islets, and reprogramming. Our experience in these areas will be described, with emphasis on the strengths and weaknesses of each of these approaches.","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":" ","pages":""},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49605063","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction The discovery of insulin is a landmark of medical history: it introduced life-saving treatment for a previously fatal disease and brought hope to millions. The research studies of Banting and Best in Toronto during the summer of 1921 have been recounted many times over. So also have the later contributions of Collip and Macleod, leading to refinements of the pancreatic extracts and their successful administration to Leonard Thompson in January of 1922.1 The award of the Nobel Prize and the commercialisation of insulin are also well rehearsed postscripts to the discovery story, but comparatively little consideration has been accorded to events of the late 1800s and early 1900s that led up to the work in Toronto: these events are focused upon here.
{"title":"discovery of insulin","authors":"K. Alberti, Clifford J. Bailey","doi":"10.15277/bjd.2022.352","DOIUrl":"https://doi.org/10.15277/bjd.2022.352","url":null,"abstract":"Introduction The discovery of insulin is a landmark of medical history: it introduced life-saving treatment for a previously fatal disease and brought hope to millions. The research studies of Banting and Best in Toronto during the summer of 1921 have been recounted many times over. So also have the later contributions of Collip and Macleod, leading to refinements of the pancreatic extracts and their successful administration to Leonard Thompson in January of 1922.1 The award of the Nobel Prize and the commercialisation of insulin are also well rehearsed postscripts to the discovery story, but comparatively little consideration has been accorded to events of the late 1800s and early 1900s that led up to the work in Toronto: these events are focused upon here.","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":" ","pages":""},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46604239","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Life of RD Lawrence (1892-1968) - pioneering doctor and survivor of diabetes","authors":"Hugo Lawrence","doi":"10.15277/bjd.2022.353","DOIUrl":"https://doi.org/10.15277/bjd.2022.353","url":null,"abstract":"","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":" ","pages":""},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46827913","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Gazing into the future: the next 100 years of training from the YDEF perspective","authors":"Giulia Argentesi","doi":"10.15277/bjd.2022.378","DOIUrl":"https://doi.org/10.15277/bjd.2022.378","url":null,"abstract":"","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":" ","pages":""},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47688418","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Impaired awareness of hypoglycaemia (IAH), defined either clinically as the loss of subjective awareness of hypoglycaemia before the onset of cognitive impairment or biochemically as the loss of symptom perception until plasma glucose has fallen below 3 mmol/L (54 mg/dl), is the major modifiable risk factor for severe hypoglycaemia in T1DM and possibly in insulin-treated T2DM. This paper tells the story of IAH, its pathogenesis and its implications and the treatment strategies used to address it.
{"title":"Impaired awareness of hypoglycaemia","authors":"S. Amiel","doi":"10.15277/bjd.2022.358","DOIUrl":"https://doi.org/10.15277/bjd.2022.358","url":null,"abstract":"Impaired awareness of hypoglycaemia (IAH), defined either clinically as the loss of subjective awareness of hypoglycaemia before the onset of cognitive impairment or biochemically as the loss of symptom perception until plasma glucose has fallen below 3 mmol/L (54 mg/dl), is the major modifiable risk factor for severe hypoglycaemia in T1DM and possibly in insulin-treated T2DM. This paper tells the story of IAH, its pathogenesis and its implications and the treatment strategies used to address it.","PeriodicalId":42951,"journal":{"name":"British Journal of Diabetes","volume":" ","pages":""},"PeriodicalIF":0.6,"publicationDate":"2022-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47950734","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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