Passing the torch: looking back with pride, forward with hope

Well, I have now to pen my last editorial for the journal! After 42 years in the NHS, my retirement is finally upon me. Throughout my career, I have been privileged to have travelled the world – attending and speaking at educational events, contributing to global research projects, engaging with leading figures in diabetes care and culminating in the great honour of receiving a lifetime achievement award from the Primary Care Diabetes and Obesity Society. All this from very humble beginnings as a student nurse in Yeovil, Somerset, where I have spent my whole career striving to improve the care of people with diabetes. 

After qualifying, I spent three years working as a staff nurse in a care of the elderly unit before taking up the position of diabetes nurse specialist. This was not only the first diabetes nurse specialist post in Somerset, but also just the second specialist nursing role in the entire hospital (the other being a breast and stoma care nurse). I took up this role in the same year as the landmark St Vincent Declaration. 

In 1989, European government representatives, diabetes experts and patient groups met in St Vincent, Italy, to address the growing challenge of managing diabetes. During the meeting, titled Diabetes Mellitus in Europe: a problem for all ages in all countries, they set out an ambitious five-year model for diabetes prevention and self-care. One of the main aims was to “implement effective measures for the prevention of costly complications”, with the following stated targets:

• Reduce new blindness due to diabetes by one third or more. 
• Reduce numbers of people entering end-stage diabetic renal failure by at least one third.
• Reduce by one half the rate of limb amputations for diabetic gangrene. 
• Cut morbidity and mortality from coronary heart disease in the diabetic by vigorous programmes of risk factor reduction.
• Achieve pregnancy outcome in the diabetic woman that approximates that of the non-diabetic woman.

Although these targets were honourable, we sadly have still not entirely met them some four decades later.

Despite this, during my career I have seen some of the most amazing advances in care and care delivery. While the following list is not exhaustive, the main changes seen in my career include:

1. The recognition that type 2 diabetes is not an inevitably progressive condition – it can be put into remission. This has seen such a shift in our focus and approach to care.
2. Greater recognition of diabetes types beyond 1 and 2, alongside advances in diagnosing monogenic forms and the growing awareness of pancreatic (type 3c) diabetes. From my very early days managing diabetes, I was struck by some cases in which the “diabetes” did not behave in the way one would expect – we used terms like “brittle diabetes” or, more sadly, labelled people as “non-compliant” when glycaemic targets could not be achieved. I have since become a great advocate for the recognition of other forms of diabetes and am convinced that, in time, many further advances will be made in this field and other diabetes types discovered. In fact, earlier this year type 5 diabetes was officially recognised by the International Diabetes Federation.
3. The massive advances in glucose monitoring. In those early days, I spent my time teaching people to monitor their urine, as it was the only way we had of assessing daily glucose levels. I remember the first blood glucose monitoring meters, which required an age and an armful of blood to get a result! In clinics (which lasted most of the day and into the evening), we would ask people to perform a filter paper series prior to their appointment. A strip of filter paper with seven circles on it would be sent to them. In the days before their appointment, they were expected to draw blood at different times across seven days and fill the corresponding circle. This would be sent to the lab for analysis before we saw them in the clinic room. How times have changed! We can now review their 24-hour glucose profiles remotely and, more importantly, they can see in real time how factors such as food, exercise, illness and alcohol affect their glucose levels. This enables the person to learn about their condition and to self-manage it to a greater degree than ever before – finally addressing one of the desires of the St Vincent Declaration.
4. The advances in technology for those with type 1 diabetes. In particular, the development of hybrid closed-loop insulin therapy has been game-changing for people with the condition. Knowing how technology never stands still, I am sure that this development in this field will be rapid.
5. In terms of type 1 diabetes, it fills me with absolute joy that we are stepping ever closer to finding the holy grail of a cure. Pioneering work is taking place is in two areas: turning off the immune destruction of islet cells from diagnosis and finding those at risk early enough to prevent the disease process before it starts. Again, from my beginnings, this was the one wish/question/hope that people with type 1 diabetes would ask me about time and again.
6. Advancements in medication classes available for those with type 2 diabetes. I remember the launch of a drug called troglitazone, the forerunner to pioglitazone and rosiglitazone. Although these drugs caused many problems, which I will not detail here, they led to the important stipulation that all new diabetes drugs must demonstrate cardiovascular safety before approval. As such, it is now part of our DNA to be discussing the findings of cardiovascular outcome trials (CVOTs). Through CVOTs we discovered, years before we would otherwise have known, that some classes are not only cardiovascularly safe but confer cardiovascular benefits. This led to the widespread use of two new classes – the SGLT2 inhibitors and the incretin mimetics (GLP-1 and dual GIP/GLP-1 receptor agonists) – for their additional benefits beyond diabetes. Again, we can finally say that we are in reach of some of the St Vincent aims – if only a few decades late!

There are many, many more highlights to my career, including the pleasure of working with numerous amazing people, but for now, I will draw this to a close.

I am handing the Editor-in-Chief reins to my very good friend and colleague, Julie Brake, with every confidence that she will carry the journal to great things. It has been my absolute honour to hold this position and to write for you over the last eight years. Since my first editorial in January 2018, we have covered many monumental occasions and witnessed many global events beyond diabetes – changes of government, nursing strikes, COVID, Brexit, and royal births and deaths, to name but a few.

It has been a joyous time for me, and I now look forward with excitement to the next chapter of what life has to offer. So, with that, I will sign off by wishing you all a joyful festive season and best wishes for the future!