Status of Diabetes Care: New Challenges, New Concepts, New Measures—Focusing on the Future!

With the release of this issue, our editorial team is now at the 3.5-year mark in our tenure of overseeing the scientific aspects of Diabetes Care. During this time, we have done our best to keep you up to date on all changes, innovations, progress, and successes of the journal. We realize that with each issue we are responsible for providing new information to help health care professionals care for people with diabetes and to stimulate the research community in its quest for new discoveries and new treatment paradigms. At this time last year, our editorial on the status of Diabetes Care was titled “It Just Doesn’t Get Any Better … or Does It?” (1). We also questioned whether in another 12 months we would “still be asking, ‘Can it possibly get any better than this?’” With this report, we feel that question has clearly been answered in the affirmative. A new norm for excellence has been established at Diabetes Care.

Over the last year, the number of new submissions reached record levels and the quality of the published articles (our primary metric) has never been higher. Moreover, the range of topics our journal covers is unlike that of any other. In the last year, we presented reports on new medications, new combinations of medications, critical reviews of safety of commercially available agents, extended outcomes of bariatric surgery, new data on the microbiome, latest developments in the artificial pancreas, staggering data on economic costs and analysis, emerging ideas on the pathogenesis of type 2 diabetes, functional imaging studies, cognitive outcomes, and corneal nerve morphology, just to name a few—the list goes on and on!

The journal also disseminates Scientific Statements, Consensus Reports, and Position Statements carefully prepared by the American Diabetes Association (ADA) (see Table 1 for highlighted articles). This past year, we were honored to publish the Position Statements “Type 1 Diabetes Through the Life Span,” “Care of Young Children With Diabetes in the Child Care Setting,” and “BMI Cut Points to Identify At-Risk Asian Americans for Type 2 Diabetes Screening” (2–4), as well as the joint Position Statement of the ADA and the European Association for the Study of Diabetes on the management of hyperglycemia in type 2 diabetes (5). Accompanying the update from the ADA/European Association for the Study of Diabetes was a report that examined the ADA Standards of Medical Care in Diabetes recommendations and trends in the quality of evidence supporting the recommendations (6). Over the 9-year period spanning from 2005 to 2014, the proportion of recommendations per year that were based on higher-level evidence increased from 39 to 51% (6). As we stated in the January 2015 update, the process for review from the ADA is working to the benefit of clinicians (7). In addition to the position statements, in October 2014, the journal published a Scientific Statement from the American Heart Association and ADA “Type 1 Diabetes Mellitus and Cardiovascular Disease” (8), and in April 2015, we published an incredibly comprehensive statement on insulin pump risks and benefits (9). A report from an ADA Consensus Conference on diabetic kidney disease was published in October 2014 (10). In addition to contributions from the ADA, we are privileged to feature noteworthy lectures from recent Scientific Sessions, and this year we published Dr. Seaquist’s 2014 Presidential Address and Dr. Krolewski’s Kelly West Award Lecture on the new paradigm of diabetic nephropathy in type 1 diabetes (11,12).

Our editorial team’s signature event is now established as our own Diabetes Care Symposium at the ADA Scientific Sessions with the 4th Annual Diabetes Care Symposium being presented at the 75th Scientific Sessions in June 2015 (in Boston, MA). Each year, we attempt to refine the format and content of this event. In June 2014, we revised the format by dividing it into two 1-h sessions and selecting overarching themes. The first segment was designed to introduce a novel twist with a presentation entitled “Best of Diabetes Care.” Its purpose was to provide brief overviews of several articles felt by the Associate Editors to be some of the most noteworthy original research reports published in Diabetes Care during the past year. That segment of the program received rave reviews, so we continued the format in the 2015 symposium. The topics for this year’s “Best of Diabetes Care” included updates on clinical phenotypes and epidemiology, depression in diabetes, and hypertension/nephrology.

The second segment of this year’s program had presentations from the four selected original articles from our competition focusing on “Novel Clinical Interventions in Therapy That Impact the Management of Diabetes.” These articles are featured in this issue. The presentations included a study evaluating a novel approach to glycemic control with use of an antianginal drug (i.e., ranolazline) in subjects with type 2 diabetes and a study evaluating a novel sodium–glucose cotransporter (SGLT) 1 and 2 inhibitor as adjunctive treatment for type 1 diabetes (13,14). We also presented two studies that provided updates on the development of the artificial pancreas, the first evaluating the safety and efficacy of the fully integrated Medtronic hybrid closed-loop system in a type 1 diabetes camp and the second offering insights on predictive low-glucose suspension and nocturnal hypoglycemia in children (15,16). The success of the symposium at the ADA Scientific Sessions has also fostered interest for such a symposium at the upcoming International Diabetes Federation’s World Diabetes Congress, 30 November–4 December 2015, in Vancouver, Canada. Those articles will be published in a special symposium section in the January 2016 issue of Diabetes Care.

The most innovative feature of this year’s ADA’s symposium, however, was the recognition of those individuals who have recently been featured in our Profiles in Progress initiative. Several times a year Diabetes Care publishes an article honoring a researcher or health care professional who has made notable contributions in the field of diabetes and served as a role model and mentor for many of our readers. In a brief ceremony this year, we recognized Drs. Samuel Rahbar, Christopher Dyer Saudek, George S. Eisenbarth, Gerald M. Reaven, Frederick C. Goetz, Oscar B. Crofford, Saul Genuth, and James R. Gavin III (17–24). Finally, at each annual ADA Scientific Sessions, we also hold our Diabetes Care Editors' Expert Forum and publish its proceedings.

Another innovative strategy for our journal has been to devote a portion of selected issues to a specific focus, either as multiple reports from landmark studies (e.g., the TODAY Study [25] and DCCT/EDIC [26]) or to highlight a specific clinical and research focus (e.g., artificial pancreas [27] and diabetes prevention [28]) (Table 2). The past 6 months have seen incredibly important special issues. Specifically, our February 2015 issue was devoted to understanding and addressing disparities in access to diabetes care and the focus of research (29). The topics covered ranged from the impact of community health worker–led interventions, to a possible role of language barriers in diabetes complications, to cerebral structural changes associated with diabetic kidney disease in African Americans, and to racial differences in underlying pathophysiologic mechanisms (29). Our March 2015 issue described research related to novel combinations of SGLT1 blockers with insulin, dipeptidyl peptidase-4 inhibitors, or other therapies; favorable effects of these agents on blood pressure and weight as well as glycemic control; and new members of this class that inhibit both SGLT1 and SGLT2 (30). Finally, perhaps our most innovative issue to date appeared just last month. We devoted the June 2015 issue to type 1 diabetes under the title “Type 1 Diabetes at a Crossroads” (31). This issue had contributions from leaders in the field and described research related to the present status of treatment methods and clinical outcomes in type 1 diabetes in the U.S.; discussed current concepts on pathogenesis, prediction, and prevention of the disease; reviewed the successes and ongoing challenges of islet transplantation; and described a pathway for the translation of advances in diabetes technology into an artificial pancreas suitable for home use by large numbers of patients (31). We will continue to present special topics in our monthly issues, based on the positive responses from our readers.

We are also very pleased with responses to our state-of-the-art Reviews, Bench to Clinic Symposia, and Perspectives in Care. Topics of these feature articles have in the past year included patient preferences for noninsulin diabetes medications (32), the association between diabetes and depression (33), the challenges for people with diabetes at high altitude (34), natriuretic peptides (35), hyperosmolar hyperglycemic states (36), and dipeptidyl peptidase-4 inhibitors and microvascular complications (37). A comprehensive review on the SEARCH for Diabetes in Youth study, for which major findings were highlighted and future directions identified for this important cohort was published in December 2014 (38). We recently added to this list a fascinating discussion of the role of the gut microbiome (39) and provided what is felt to be the most up-to-date review on the evaluation and treatment of obesity in type 2 diabetes (40).

We also continue to feature debates in a Point-Counterpoint format. In an elegant debate this past year, Dr. Abrahamson provided his argument suggesting that avoiding use of sulfonylureas as a class of medication as an add-on to metformin is not appropriate as there are many patients whose glycemic control would improve with use of these drugs with minimal risk of adverse events (41). In the counterpoint narrative, Dr. Genuth suggested there is no longer a need for sulfonylureas to remain a first-line addition to metformin for those patients whose clinical characteristics are appropriate and whose health insurance and/or financial resources make an alternative drug affordable (42).

In closing, to our editorial team, Diabetes Care is a living thing, alive and growing, and is also getting better over time. We take pride in every issue, pay attention to every submission, and continue to strive for improvement. The bar for acceptance of manuscripts has steadily risen and, to the chagrin of many authors, our rejection rate continues to climb.

So, in getting back to the original question asked in July 2014—Can it possibly get any better than this?—we think we know the answer and will continue to focus on the future through new challenges, new concepts, and new measures.