Thirty Years of Diabetes Care: Reflections on the Beginning

The 1970s saw an explosion of clinical research in diabetes. In that decade the following was introduced: highly purified insulin, U-100 insulin, basal-bolus insulin therapy, self-monitoring of blood glucose, glycosylated hemoglobin measurement, insulin pumps, laser photocoagulation, pancreas transplantation, the concept of specialized diabetes educators, and diabetes management teams. In 1975, the National Commission on Diabetes (1) was convened, and its report led to a marked expansion of National Institutes of Health–supported diabetes research, including the creation of Diabetes Centers. In response to these burgeoning advances, the American Diabetes Association (ADA) questioned whether its existing scientific journal Diabetes was adequately answering the needs of clinical investigators and clinicians caring for patients with diabetes.

To study the question, ADA created an ad hoc committee under the chairmanship of T. Franklin Williams. The committee concluded that, indeed, a second journal with a more clinical focus was needed. Several potential plans were considered. In the end, the committee chose to launch a peer-reviewed journal focusing on clinical research. Although some thought a review journal might better serve the needs of clinicians, the need for a peer-reviewed journal was felt to be sufficiently high that that plan won out. Nonetheless, some, led by ADA President Donnell Etzwiler, questioned whether there was enough high-quality diabetes clinical research to warrant a whole journal. That group wondered whether the focus should be broadened to health care in general, with diabetes as a model.

Indeed, the original working name of the journal was to be Diabetes Health Care so that it could include both diabetes and general health care articles. Others, led by President-Elect George Cahill, argued that that was too diffuse and the journal should maintain its diabetes focus. Clinical Diabetes or Diabetes—Clinical were proposed as titles. Both were vetoed by the then Editor of Diabetes, David Kipnis, who feared that either selection would relegate Diabetes to be considered as Diabetes—Basic whether or not it was so named. He wanted research in clinical physiology to still be included in Diabetes and for that journal to not be confined to animal or in vitro studies. Meanwhile, a totally different force—the new discipline of diabetes educators—was emerging. They argued that the new journal should also focus on education. The compromise reached was the name Diabetes Care with “Care” also an acronym for “Clinical and Applied Research and Education.” Thus, the name was chosen and the description “Clinical and Applied Research and Education” has been included on the cover or contents page throughout the 30 years of existence of Diabetes Care.

The Williams Ad Hoc Committee asked me to serve as Editor for three reasons: 1) Don Etzwiler had proposed me for this role; 2) the committee selected my plan for Diabetes Care, i.e., that from the beginning there would be a focus on peer-reviewed original articles; and 3) no one else wanted the job—most of the leadership of ADA thought that Diabetes Care would fail, and they wanted to stay as far away from anticipated failure as they possibly could.

Nonetheless, many distinguished diabetologists, with a little arm twisting, were willing to contribute articles that might be used in the first issues. Indeed, volume 1, number 1, included the first description of truncal neuropathy by Max Ellenberg from New York (2), one of the first studies with long-term results of pancreas transplantation by Harold Rifkin and colleagues from Albert Einstein College of Medicine (3), and the first experiences with self-monitoring of blood glucose (SMBG) in two articles, one by Ted Danowski and colleagues from Pittsburgh (4) and the other within Diabetes Care's first review article, which was on diabetes and pregnancy, by Dan Mintz, Ron Chez, and me (5). The Danowski and Sunder article also included the first description of basal-bolus therapy. Yet, this seminal article, describing both SMBG and basal-bolus therapy, is rarely cited as such. Unfortunately, Danowski and Sunder's article was titled “Jet Injection of Insulin During Self-Monitoring of Blood Glucose,” and the focus on jet injection obscured the real essence of the article. Danowski actually wanted to introduce blood glucose monitoring to patients, but automated lancets were not yet available. In an attempt to convince patients to test frequently, he thought that offering a jet spray to deliver insulin would obviate the insulin injections and would be a reasonable trade for testing blood. The jet devices he had could only deliver one type of insulin, so he used an approach that he favored anyway: regular insulin before each meal and bedtime NPH as overnight basal insulin.

During the first year of Diabetes Care I also intentionally included an article that might be criticized today as “duplicate” publication. Jean Pirart from Brussels had published in French in Diabète et Métabolisme his 4,400-patient prospective 25-year observational study that examined the relationship between diabetes control and complications (6). With permission from both Pirart and the French journal, I commissioned a translator to render an English version and published it in two parts (7). It received much acclaim as a seminal set of observations that might have escaped notice of most of the world if only published in French. Moreover, it helped establish Diabetes Care as a journal that clinicians and clinical investigators wanted to read. And Diabetes Care was indexed in both Index Medicus and Current Contents.

We stayed the course in the early days, although often it was a struggle to have enough articles to fill an issue even though we were publishing very thin issues only six times per year. Yet, we didn’t want to sacrifice the peer-review process. This created some interesting situations. To increase submissions, after a scientific meeting, I would write a personal letter to the authors of clinically relevant abstracts that I found interesting, requesting that they consider Diabetes Care as a place to publish. Unfortunately, I was left in the position of having to reject quite a few articles that I had invited to be submitted. Although I had only promised a rapid decision and rapid publication if accepted, and had not promised acceptance, irate authors felt misled; some have never forgiven me, and one even continues to publish my rejection letter on his Web site.

A big boost to Diabetes Care came from Robert Kroc (a member of the Williams Ad Hoc Committee). Not only did the Kroc Foundation offer financial support for the creation of Diabetes Care, but Bob directed to Diabetes Care several symposia emanating from Kroc Foundation conferences. The first of these was on the “Epidemiology of Diabetes and Its Macrovascular Complications,” (8) chaired by Kelly West. Among its many important epidemiologic articles were three studies that contained the first descriptions of circulating insulin levels as a risk factor for atherosclerosis. Several symposia, both Kroc Foundation and otherwise, helped Diabetes Care become noted and resulted in increased submissions. Among the articles that we recruited were the first description of the “dawn phenomenon” (9) and the first article demonstrating that insulin therapy of type 2 diabetes improved both pancreatic insulin secretion and insulin action (10), which was later to be recognized as correction of glucose toxicity.

During those first years, under my editorship, Diabetes Care came to have the highest subscription base of any professional journal in the field of endocrinology, diabetes, and metabolism. We also had the largest number of pages of advertising. Thus, we were widely read and financially successful. I felt fulfilled in having the privilege to steward the journal through its early years and happily turned it over to John Service, Bob Rizza, and Bruce Zimmerman at Mayo Clinic to take the journal through its next phase. Thereafter, the editorship would meander across the country, to Vermont, Washington, Pittsburgh, Indianapolis, Los Angeles, and New Orleans (Table 1).

In 1991, Diabetes Care expanded to 12 issues per year, following a brief period (1988–1990) with 10 issues per year. Featured reviews became prominent every third issue from 1990 to 1992, with Ralph DeFronzo serving as Reviews Editor, before ADA's spin-off journal Diabetes Reviews, from 1993 to 1999. Unfortunately, Diabetes Reviews never got traction due to low numbers of subscriptions, low numbers of advertisements, and lack of inclusion in Index Medicus. ADA thus abandoned Diabetes Reviews, and reviews again became a prominent feature of Diabetes Care.

The number of published pages expanded as well (Fig. 1). In spite of this, the acceptance rate has continued to drop, due to the constantly increasing number of submissions, which totaled 2,489 in 2006. This results in increased quality and increased citation. As a consequence, the impact factor of Diabetes Care has progressively increased to 7.912 in 2006, so that it now is almost identical to that of its sister publication Diabetes (7.955 in 2006), and these two journals have a commanding lead over all other nonreview journals in the field of endocrinology, diabetes, and metabolism.

With this issue, Diabetes Care embarks on its 31st year, having successfully matured over its first 30 years. Parents are always proud of their children, particularly as they mature and make their independent mark on the world. As I stand back and reflect on the 30 years of Diabetes Care I am indeed a proud father of this my eldest child. And I trust that my other three children—two lawyers and a sex therapist—are not as jealous of this child as they sometimes seem to be of my cocker spaniel.