Joslin was involved for seven decades in most aspects of diabetes investigation and treatment, save for the fact that he did not discover insulin. Following the Toronto group's blockbuster discovery of insulin in 1921, and the group's disbanding several years later, Joslin became effectively the dean of diabetes mellitus. In the mid-1920s, Joslin, in his mid-50s, took the reins as the world spokesman for the "cause of diabetes." He was the first to advocate for teaching patients to care for their own diabetes, an approach now commonly referred to as DSME or Diabetes Self-Management Education. He is also a recognized pioneer in glucose management, identifying that tight glucose control leads to fewer and less extreme complications.[1]
Elliott Joslin was born to wealthy parents in 1869 in Oxford, Massachusetts, where his father was a mill owner. He was educated at Leicester Academy, Yale College and Harvard Medical School. After graduating from Yale, Elliott Joslin extended his time at the university by enrolling in a master's degree in physiological chemistry. This interest in chemistry, along with his aunt's recent diagnosis of diabetes, led him to an interest in diabetes and metabolic disease.[4]
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From the beginning of his medical practice he kept a diabetes registry, the first of its kind in the world. His carefully assembled data from his medical ledgers eventually allowed him to predict a global diabetes epidemic that is evident today. In 1908, in conjunction with physiologist Francis G. Benedict, Joslin carried out extensive metabolic balance studies examining fasting and feeding in patients with varying severities of diabetes. His findings would help to validate the observations of Frederick Madison Allen regarding the benefit of carbohydrate- and calorie-restricted diets. The patients were admitted to units at New England Deaconess Hospital, helping to initiate a program to help train nurses to supervise the rigorous diet program.
Joslin was an educator at heart and advocated total immersion of his patients and families in classroom education. He felt that careful monitoring of diabetes that rendered good control would allow the patient to avoid chronic complications of diabetes along with prevention of acute acidosis.[5] Joslin included the findings from 1,000 of his own cases in his 1916 monograph The Treatment of Diabetes Mellitus, the first textbook on diabetes in the English language. Here he noted a 20 percent decrease in the mortality of patients after instituting a program of diet and exercise. This physician's handbook had 10 more editions in his lifetime and established Joslin as a world leader in diabetes.
When insulin became available as therapy in 1922, Joslin's corps of nurses became the forerunners of certified diabetes educators, providing instruction in diet, exercise, foot care and insulin dosing, and established camps for children with diabetes throughout New England. With insulin available, Joslin enlarged his medical practice into a team that evolved into the Joslin Clinic, which was affiliated with the New England Deaconess Hospital and the Harvard Medical School.
Joslin's associates were chosen to expand his interests in foot salvage for the middle aged diabetic prone to peripheral vascular disease as well as group education for diabetics in the hospital setting. This later expanded to include the first nurse educator service and children's diabetic camps. His proteges, including Alexander Marble and Priscilla White, followed his mandate to investigate problems in diabetes and metabolism. Marble became Joslin's first research director, and White created the first "high risk" pregnancy clinic aimed at improving outcomes for infants and the insulin-dependent woman during pregnancy and at delivery.
The first hospital blood glucose monitoring system for pre-meal testing was developed under Joslin's direction before 1940 and was the forerunner of the modern glucometer era. Joslin was also the first to name diabetes a serious public health issue. Just after WWII, he expressed concern to the Surgeon General of the U.S. Public Health Service that diabetes was an epidemic, and challenged the government to do a study in his hometown, Oxford, Massachusetts. The study was started in 1946 and soon confirmed the true incidence of diabetes in the general population (including a percentage of cases that went undetected). The study was carried out over the next 20 years. The results would later confirm Joslin's fear that the incidence of diabetes in the United States was approaching epidemic proportions. He has been named as being, with Frederick Madison Allen, one of the two leading diabetologists from the pre-Insulin period between 1910 and 1920.[7] [8]
In 1952, Joslin's group practice became officially known as the Joslin Clinic. In 1956, the office moved to its current location at One Joslin Place in Boston. It was the world's first diabetes care facility, and today maintains its place as the largest diabetes clinic in the world.
Joslin was adamant in his position that good glucose control, achieved through a restricted carbohydrate diet, exercise, and frequent testing and insulin adjustment, would prevent complications. This was debated for decades by other endocrinologists and scientists, and the American Diabetes Association was divided on this subject from its inception. The opposing point of view, led by Edward Tolstoi, held that tight control had little long-term effect, but a profound effect on lifestyle.[9]
Joslin's tight control approach wasn't validated until 30 years after his death, when in 1993, a 10-year study, the Diabetes Control and Complications Trial Report was published in the New England Journal of Medicine.[10] The study showed significant reduction in retinopathy among a group of patients following tight control of their glucose as compared to those who underwent their usual routine. Furthermore, these patients reported no reduction in their lifestyle.
Before the discovery of insulin, Joslin and Frederick Madison Allen promoted fasting and undernutrition to treat diabetic patients. Critics referred to this as "starvation dieting," and some patients starved to death.[7]
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We abstracted clinical data from the medical records of 700 pregnant women from 2004 to 2017. For each time period, means and percentages were calculated. P values for trend were calculated using linear and logistic regression.
The prevalence of type 1 diabetes mellitus in pregnancy has almost doubled in the past few decades in the US [1]. Of concern, numerous studies show that maternal and fetal complications, such as perinatal mortality and fetal macrosomia, are substantially higher in women with type 1 diabetes than in women from the general population [2, 3]. In addition, pregnancies complicated by type 1 diabetes have a higher prevalence of cesarean section, preterm birth, and macrosomia and incur higher health care costs than pregnancies complicated by type 2 diabetes or gestational diabetes [4]. Optimization of glycemic control before and during pregnancy in women with type 1 diabetes is critical for improving pregnancy and delivery outcomes [5]. Interestingly, concurrent with the increase in type 1 diabetes prevalence, there have been rapid advances in technology for the purpose of improving glycemic control, including insulin pumps and continuous glucose monitors (CGM). However, it is unclear how widely technology to treat type 1 diabetes has been adopted for use in pregnancy or whether this has had any impact on pregnancy and delivery outcomes.
We aimed to examine time trends in prepregnancy maternal characteristics, treatment, and glucose control measures, along with pregnancy and delivery outcomes among US women with type 1 diabetes. With rapid advances in technology to treat type 1 diabetes, including the introduction of CGMs and the increasing use of insulin pumps, evaluating time trends for pregnancy and delivery outcomes could provide insights about this high-risk US population.
Clinical data were abstracted from the medical records of pregnant women with type 1 diabetes seeking care at the Joslin Diabetes Center and Beth Israel Deaconess Medical Center (BIDMC) Diabetes in Pregnancy Program. Most deliveries (663) were at BIDMC, however 37 deliveries occurred at other hospitals. Eligible women had clinically diagnosed type 1 diabetes, were 18 years or older with a singleton live birth pregnancy and delivered at BIDMC in the time period of 2004 through 2017. All women were managed by a multidisciplinary team that included endocrinologists, maternal-fetal medicine specialists, nurses, and dieticians. We included women who had multiple pregnancies as well. The study was approved by the Committee for Human Subjects at Joslin Diabetes Center.
Data on delivery mode, gestational age at birth, and birthweight were obtained from the medical records. We evaluated vaginal versus cesarean deliveries based on delivery records. Gestational age was based on last menstrual period and assessed as a continuous variable. In addition, preterm delivery was defined as 90th percentile were classified as LGA. Those with birthweight below the 10th percentile were classified as small for gestational age (SGA). Infants with birthweight between the 10th and 90th percentile were considered as appropriate for gestational age.
In Table 2, we present the mean values of HbA1c during pregnancy. When analyzed continuously, there were no differences between the three groups for any trimester. In addition, we examined the percentage of women who reached the recommended levels of HbA1c in each trimester ( 152ee80cbc
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