Editorial: A tribute to Dr Michael Mosley

We have plenty of fascinating reading in this issue, with a mix of lifestyle and pharmacological content which reflects the fact that, in the management of diabetes, an approach that combines the two is needed. While it is encouraging to see exciting new therapies and technologies launched, and many more in development, it is important we don’t lose sight of the impact of lifestyle interventions.

My colleague and good friend, Dr Pam Brown, has a particular interest in lifestyle medicine and has contributed numerous articles on this topic for the journal over the years. As joint Editors-in-Chief of the journal for several years, we were always keen to ensure that this fundamentally important element of diabetes management was covered. So I am grateful to Pam for joining me in writing this tribute to Dr Michael Mosley, who very sadly passed away on the Greek Island of Symi last month.

Tribute to Dr Michael Mosley

As clinicians with a passion for nutrition and lifestyle medicine, we have been hugely influenced by the professional ethos and life’s work of Michael Mosley to inspire both healthcare professionals and the people we support in our practice. By reaching out directly and appealing to the general public, Dr Mosley helped shape, influence and disseminate lifestyle education which has had a lasting impact on improving health and wellbeing, across the UK and internationally.

Dr Mosley’s scientifically accurate education resonated with a wide audience, including clinicians, politicians and public health, and even individuals who had previously lacked interest in taking action and responsibility to improve their own health.

Michael was perhaps best known for his work popularising intermittent fasting, introducing the public to the 5:2 diet developed by Michelle Harvie, Mark Mattson and colleagues. His books, including The Fast Diet and The Fast 800, along with supporting recipe books written by his wife, Dr Clare Bailey, helped many people to lose weight and even achieve type 2 diabetes remission for some. In this journal, Clare shared his 8-Week Blood Sugar Diet book in our series on “What people with diabetes are reading”, and we have incorporated much of this into our clinical practice.

Michael also made the science supporting high-intensity exercise accessible in Fast Exercise, kickstarted public discourse about the gut microbiome and how we can care for it in The Clever Guts Diet and shared his own fight with insomnia in Fast Asleep, later sharing his Four Weeks to Better Sleep programme, offering hope and practical guidance to help people improve this increasingly recognised area of lifestyle. His BBC Just One Thing podcast spawned the book of the same name, and both were crammed full of ideas for simple, scientifically supported, small changes everyone can make to improve their health and wellbeing.

Michael was able to distil out and share key messages in a way which made them interesting and compelling. His ability to translate evidence-based science into an optimistic, credible and entertaining format made it so much more likely that even the most reluctant people would engage and be motivated to make lifestyle changes.

Dr Mosley suffered an untimely and cruel death, and our hearts go out to Clare and the family he leaves behind. However, he has left a wonderful legacy, for which we are all truly grateful. The work on lifestyle that he pioneered and the healthier lives of the people he influenced will continue far into the future.

Pam Brown, Jane Diggle

In this issue: Food, fasting, falling asleep and cardiovascular disease

Given the increasing popularity of intermittent fasting and the publicity around it that Michael’s death has doubtless brought, we thought it timely to explore the different approaches and what we, as clinicians, need to know to support those individuals who are considering them. In our At a glance factsheet, Michelle Harvie, one of the originators of the 5:2 diet, and Sarah McDiarmid offer a summary of the different regimens, highlighting the supporting evidence and benefits but also the potential risks and important contraindications. There are helpful recommendations around adjusting medication for those who decide to adopt such an approach.

Eating healthily and being physically active does not guarantee that an individual will avoid illness or infection completely, although it is likely to strengthen a person’s immune system, making it easier to fight an infection. There has been much interest in whether a healthy lifestyle decreases the risk of worse outcomes, particularly following the COVID-19 pandemic, when it became apparent that people with diabetes were disproportionately adversely affected. People with diabetes have a 1.5–4-fold increased risk of infection in general – not just COVID-19 but a whole host of infections, including kidney and foot infections, pneumonia, influenza, tuberculosis and sepsis. Read more about the underlying mechanisms and how we prevent and manage specific infections associated with diabetes in Pam’s deep dive into diabetes and infection.

Instinctively, I feel we are all more susceptible to illness and infection when we are tired and run down. Sleep is centrally important to our wellbeing and, indeed, our survival. Although it is one of the pillars of lifestyle medicine (and a topic we covered in our lifestyle factsheet series), I suspect it does not routinely feature in our lifestyle conversations during routine diabetes reviews. Interestingly, there is a significant association between sleep quantity, quality and timing and the development of type 2 diabetes, with a far greater risk for “night owls” compared with “larks”. To learn more about this fascinating topic, including links to additional practical resources and tips on four simple questions we could easily incorporate into routine reviews, see our Diabetes Distilled summary.

Sleep is also an important component of cardiovascular health and there is a complex bidirectional relationship between the two (Jaspan et al, 2024). In this issue, there is a keen focus on cardiovascular disease. Building on last issue’s How to diagnose and treat hypertension in adults with type 2 diabetes, I have updated our Need to know guide on blood pressure readings and targets to reflect NICE’s updated NG136 guideline on hypertension (NICE, 2023a). I hope this printable one-page guide helps when setting clinic and home blood pressure targets according to a person’s age, diabetes type and presence of chronic kidney disease.

The other cornerstone of cardiovascular disease risk reduction is lipid management, and a few years ago we posed an array of lipid-related questions for a Q&A. Things have moved on at pace since then, and NICE has updated its guidance on this (NICE, 2023b), so Claire Davies, a Diabetes and Endocrinology Specialist Pharmacist in Gateshead, kindly agreed to review the responses to align them with the updated recommendations. In this issue, we have Part 1, on measuring lipids and lipid targets, and Part 2, on the use of statins. If you recall, Claire also wrote an At a glance factsheet on the newer lipid-lowering therapies, which is perhaps worth revisiting while you’re focused on this topic. Look out for Part 3 of this Q&A series next time!

Finally, if you’re keen to put all this learning into practice, we have three interactive cases for you to work through, focusing on the primary and secondary prevention of cardiovascular disease in people with type 2 diabetes.

The UK Prospective Diabetes Study (UKPDS) is one of the longest ever clinical trials in type 2 diabetes. The 20-year trial results were published in 1998 and showed that tight blood glucose control reduced the risk of diabetes-related complications. Ten years later, the post-trial monitoring study showed that those participants who had been allocated to early intensive blood glucose control continued to experience fewer diabetes complications, a phenomenon we now refer to as the “legacy effect”. This is reflected in current guidelines, which advocate early intensive blood glucose control for everyone with type 2 diabetes. Here we provide a summary of the findings from UKPDS at 44 years – up to 24 years after the end of the study. It is a poignant reminder of the benefits of intensive blood glucose control immediately after type 2 diabetes diagnosis: something that should be foremost in our minds at that initial type 2 diabetes consultation.

Our final Diabetes Distilled entry this issue summarises the FLOW trial of semaglutide in the treatment of chronic kidney disease. The study, the first renal outcomes trial of a GLP-1 receptor agonist, was halted early due to evidence of benefit, and the exciting results suggest we may soon have another class of agents to reduce risk of renal progression and cardiovascular disease in this high-risk population.

The latter summary forms part of our coverage of the 2024 ADA Scientific Sessions, held on 21–24 June. We will package up our full report of this meeting in the next few weeks, but in the meantime readers who wish to stay on top of our coverage as soon as it is published can view it here.

It won’t be too long before the “conference season” over here is in full swing. Those of you who are working near London have a few more days to sign up for the PCDS Smart Update on diabetes, obesity and multiple long-term conditions on 12 July, and we have the Northern Ireland conference in September, the Scotland conference in October and the National conference in November. The 15^th Welsh Conference of the PCDS took place in Cardiff on 16 May 2024. Our short Conference over coffee report highlights the key messages and is helpful not only for those who were unable to attend but also for anyone looking for simple tips and ideas to implement in their practice.

There’s plenty to read! I hope you enjoy this issue and have a lovely summer!