Diabetes

ABC of Diabetes
by Peter J. Watkins

Introduction

Advances in clinical science over a single professional lifetime during the second half of the 20th century have led to improvements in understanding the causes and complications of diabetes, together with alleviation of suffering to an extraordinary degree, unimaginable even 25 years ago. Many of the clinical improvements have been initiated at innovative centres across the United Kingdom.

In the 1960s and 1970s physicians had to stand by helplessly watching their patients overwhelmed by complications of the disease. Prevention of blindness by photocoagulation and renal support treatment for those in renal failure became possible in the 1970s, while development of specialist foot clinics during the 1980s succeeded in halving the amputation rate. The sad outcome for pregnancies even 20 years after the discovery of insulin when the fetal mortality rate was more than 25%, has been transformed so that now more than 95% of these pregnancies succeed. And now, the landmark Diabetes Control and Complications Trial (DCCT) of Type 1 diabetes in the United States, and more recently the astonishing achievement of the late Professor Robert Turner in completing the United Kingdom Perspective Diabetes Survey (UKPDS) of Type 2 diabetes have demonstrated how to reduce the incidence and progression of diabetic complications by good treatment.

Yet there is still more. The present technology of managing diabetes was undreamt of until the last quarter of the 20th century. The introduction of home blood glucose monitoring with new non-invasive technologies now in sight, has made possible the achievement of “tight control”, while at the same time advances in understanding and reversing diminished awareness of hypoglycaemia are reducing its hazards. The invention of insulin pens and more recently the development of insulin pumps has contributed in great measure to improving the quality of life of those with the burden of lifelong diabetes. Furthermore after the British discoveries of the chemical (Frederick Sanger, 1955) and physical structure (Dorothy Hodgkin, 1969) of insulin followed by the revolution in molecular science, man-made insulin analogues have been introduced, giving further advantages in achieving good blood glucose control while minimising hypoglycaemia.

The initially controversial “invention” of the diabetes specialist nurse by Dr Joan Walker in Leicester in the 1950s is arguably one of the most important advances in health care, not only for those with diabetes but across the whole of medicine. The tremendous benefits in the delivery of care especially to those with diabetes and other chronic diseases have been accompanied by recognition of community needs and improvements in crossing the primary/secondary care interface. It is now to be hoped that improvements in information technology, more sophisticated audit, and provision of a national eye screening programme may emerge from the National Service Framework of 2002/2003.

Rapid clinical advances of this magnitude require substantial support. Diabetes UK, founded as the Diabetic Association by Dr RD Lawrence and his patient HG Wells in 1934 (later the British Diabetic Association), has uniquely supported both patients and their needs as well as clinical and scientific research. More recently the Juvenile Diabetes Foundation has made substantial contributions. Furthermore the pharmaceutical industry has been both innovative in its own laboratories as well as supportive of both patients and clinicians.

It gives particular pleasure to reproduce some parts of the personal account by Mrs B-J (with her permission) of her own diabetes over the last 70 years of attendances at King’s College Hospital. She describes vividly aspects of treatment and some of the problems faced by people with diabetes, and one can see clearly how many improvements there have been during her lifetime. Her account should give tremendous encouragement to those now starting on their own life with diabetes.

The ABC is intended as a strictly practical guide to the management of diabetes and its complications and is directed to all those doctors, nurses, and health professionals, other than established specialists, who see diabetic patients, and medical students should find some value in its pages. Many of the innovations of the end of the 20th century are described in this fifth edition of the ABC in the hope that it will help in the delivery of the very best standards of care to those who need it in the 21st century.

ABC of Diabetes - Table of Contents