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      Diabetes Care: “Taking It to the Limit One More Time”


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          With this January 2017 issue, our editorial team celebrates its 5-year anniversary at the helm of Diabetes Care. In 2012, when we accepted the assignment to oversee the scientific aspects of the journal, we envisioned that the editorial for this January 2017 issue would be our opportunity to thank the American Diabetes Association (ADA) for allowing us to lead this effort, to thank our reviewers and associate editors for their tireless efforts, and to thank the readers for their valuable suggestions and ideas. However, we are now writing to inform you that those plans have been put on hold. Our editorial team has been given the opportunity to continue to guide Diabetes Care for another 2-year period. We have accepted the invitation primarily because our “team” (including the editorial committee, editorial office, and publications staff) feels we still have creative ideas to make the journal better and considerable energy to bring these ideas to fruition. Therefore, suffice it to say, we remain honored to continue to lead Diabetes Care for this extended period. It has been our custom to summarize our productivity and achievements in both the January and June issues of each year. This year we believe the trajectory of quality continues to rise. We hope you will also agree when reading the summary presented in this narrative. We feel each year’s monthly issues have surpassed the prior year’s work, and year 2016 is no exception! As we described in July of 2016, we aim to provide the readers with lagniappe—“a little something extra”! (1). This past year the editorial team took our initiative to another level devoting several monthly issues to specific clinical or research topics. A current summary of all thematic monthly issues can be found in our Diabetes Care Online Collections (http://care.diabetesjournals.org/content/diabetes-care-online-collections). In the past year alone, we have published collections of articles on six particular topics. The January 2016 issue focused on gestational diabetes mellitus, the May issue on diabetes and cardiovascular disease, the July issue on the artificial pancreas, and the November issue on precision medicine. Two monthly special issues were particularly noteworthy as they provided a “first” in each particular field. The December 2016 issue of Diabetes Care presented nine articles on a broad spectrum of behavioral and psychosocial issues that can influence treatment success and quality of life for people living with diabetes (2). Central to this topic, and serving as the cornerstone of that issue, was the first Position Statement from the ADA for the psychosocial care of people with diabetes (3). Another “first” was presented in the June issue, which featured 12 articles supporting bariatric/metabolic surgery as a new treatment option in the management of type 2 diabetes (4). The centerpiece of this collection was a contribution from Rubino et al. (5), writing on behalf of 48 voting delegates from the 2nd Diabetes Surgery Summit (DSS-II). This international consensus conference, organized in collaboration with major diabetes organizations, proposed new evidence-based guidelines for surgical treatment of type 2 diabetes, the first in over 20 years of experience. The report summarized a large body of evidence demonstrating that several gastrointestinal operations, originally designed to promote weight loss, improved glucose homeostasis more effectively than any current pharmaceutical or behavioral approach and led to sustained improvement of glycemic control in many patients with type 2 diabetes (5). Diabetes Care was honored to be the journal chosen to disseminate these important and new treatment guidelines, which promise to help medical providers and patients alike in assessing treatment options! Our journal’s most visible signature event, the Diabetes Care Symposium held each year during the ADA Scientific Sessions, has become one of the most attended sessions during the Scientific Sessions. This year we once again revised the format and content of this event. Our efforts were rewarded by the enthusiasm of the attendees, of whom more than 3,000 were present at the end of the session. The symposium featured two talks on precision medicine, covering both initiatives from the National Institutes of Health (NIH) (6) and efforts specific to diabetes (7). Also presented were two stellar talks by Ferrannini et al. (8) and Mudaliar et al. (9), which provided novel and complimentary proposals regarding a possible role for ketone bodies as fuel for injured myocardial and renal tissues, which might in part explain the surprising cardiovascular protection demonstrated by the BI 10773 (Empagliflozin) Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME) trial. Each year in this session we also include presentations based on articles judged by the editorial committee as the “Best of Diabetes Care” for the journal for the past year. One of this year’s selections was an article from Chew and colleagues (10), on behalf of the Action to Control Cardiovascular Risk in Diabetes Follow-On (ACCORDION) Eye Study Group and the Action to Control Cardiovascular Risk in Diabetes Follow-On (ACCORDION) Study Group, reporting that prior intensive glycemic control continued to reduce diabetic retinopathy progression after return to standard therapy at the end of randomized treatment in the ACCORD Study. The other “Best of Diabetes Care” presentation was a report from Purnell et al. (11) describing metabolic remission rates following laparoscopic surgery from the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study. During the past year, and at each quarter, we have continued to acknowledge and recognize the lives and careers of individuals who have devoted their lives to diabetes research and care in our Profiles in Progress series. These individuals have shaped the diabetes landscape for generations to come through their scientific and clinical contributions in the field of diabetes and, just as importantly, in their roles as mentors and role models for all of us in their professional and personal lives. Our Profiles in Progress plaque recipients for 2015–2016 were Trevor Orchard, Philip E. Cryer, Abbas E. Kitabchi, and Maria Gordon Buse, who were featured in our September and December 2015 and March and June 2016 issues, respectively (12–15). In addition to original articles from investigators, Diabetes Care publishes narratives and updates that provide added value to our readers. As the clinical care and research journal of the ADA, we were privileged to publish the 2015 and 2016 Presidential Addresses from Drs. Dagogo-Jack and Schatz, the 2016 Health Care & Education Presidential Address from Dr. Margaret A. Powers, and the 2015 Kelly West Award Lecture from Dr. Narayan, all presented at the Scientific Sessions (16–19). Also in 2016, we disseminated the ADA Position Statements on management of diabetes in long-term care and skilled nursing facilities (20) and on physical activity/exercise and diabetes (21). A narrative of great interest on a topic of tremendous importance to the medical community, published in September, was the ADA Consensus Report on the current status, challenges, and priorities for youth-onset type 2 diabetes (22). During the past year, Diabetes Care published a number of challenging Perspectives in Care articles that address clinically relevant and controversial topics. We view Perspectives as expert narratives that highlight recent exciting research, not primarily that of the author, and provide context for the findings within a field or through interdisciplinary significance. In the past year we published a Perspective on whether the time is right for a new classification system for diabetes and also a thought-provoking one on current clinical challenges and proposed solutions for youth with type 2 diabetes (23,24). Glucose variability remains a priority topic and in the April issue, Kovatchev and Cobelli (25) provided their thoughts on its timing, risks, and relationship to hypoglycemia. Another Perspective by Welsh et al. (26) addressed the utility of glycated proteins in the diagnosis and management of diabetes, commenting on research gaps and future directions. Our journal also takes pride in the quality of its Reviews. Before a review is even considered, a proposal from the authors must be submitted and approved by the editorial committee. The proposal must outline why the proposed topic deserves a systematic review of the literature, why such a review would be best suited for Diabetes Care, and why it would appeal to the readership. Only after editorial committee approval are the authors invited to write and submit the full narrative, and then it has to survive the peer-review process. Thus, when a review is published in Diabetes Care, the reader can be assured it has been carefully vetted and can expect its quality and depth of discussion will be excellent. In the March issue we published an outstanding review of diabetes in Asia and the Pacific and the implications of the global epidemic (27). In April, we presented a review on type 1 diabetes and polycystic ovary syndrome (28) and, in October, an in-depth discussion of the mechanisms and therapeutic opportunities concerning fatty liver and chronic kidney disease (29). In November, White et al. (30) reviewed the pathologic basis of reversible β-cell dysfunction in type 2 diabetes. In addition to the Reviews, we published our 4th Annual Diabetes Care Editors’ Expert Forum that provided the most up-to-date thoughts, comments, concerns, and direction on diabetes prevention from the world leaders and investigators of the landmark prevention trials (31). Another popular feature in Diabetes Care is our Point-Counterpoint debate format. This category juxtaposes a narrative that defends a certain position in clinical treatment and/or diagnosis with a thoughtfully written opposing view. The best topics for this format are areas where scientific evidence is limited or conflicting, and thus clinical care must be guided largely by expert consensus or experience. In the July issue, we provided a discussion on the pros and cons of relaxing the renal restrictions for metformin use (32,33). The August issue featured two debates. One centered on whether we do or do not need to consider the clinical implications for racial differences in A1C. This is not a trivial issue given its implications for diagnosing and managing diabetes in different ethnic populations (34,35). Also, given the controversy surrounding the acceptance of the lower cut points for A1C and fasting glucose in the diagnosis of prediabetes as suggested by the ADA, the same issue included a debate on the implications and heightened awareness of prediabetes (36,37). Finally, in our attempt to continue to innovate and provide updated educational messages for our readers, we added an exciting new article category and format to the journal called Clinical Images in Diabetes. A Clinical Images article provides visual images obtained with modern techniques to illustrate the pathogenesis of diabetes or its complications. This category serves as a valuable educational tool to better understand the pathophysiology of diabetes, enhance disease diagnosis, and offer guidance for optimized treatment. Our first Clinical Images in Diabetes contribution on a presumptive diagnosis of type 1 diabetes appeared in the July issue (38), and a second on a diagnostic dilemma was reported in the August issue (39). In summarizing the past year’s work, we feel it continues to demonstrate our upward trajectory. We are very proud of each monthly issue, pleased with the recent innovations, and thrilled with the quality, diversity, and depth of the material we have approved for publication. It is very satisfying to us that this past year we received the highest impact factor ever in the history of the journal. So, despite being at the helm of Diabetes Care for 5 years, we are not relinquishing the “tiller” at this time. Instead, we’ve decided, as the rock band the Eagles sang in 1975, to “take it to the limit one more time”!

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          Most cited references 32

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          Can a Shift in Fuel Energetics Explain the Beneficial Cardiorenal Outcomes in the EMPA-REG OUTCOME Study? A Unifying Hypothesis.

          Type 2 diabetes mellitus causes excessive morbidity and premature cardiovascular (CV) mortality. Although tight glycemic control improves microvascular complications, its effects on macrovascular complications are unclear. The recent publication of the EMPA-REG OUTCOME study documenting impressive benefits with empagliflozin (a sodium-glucose cotransporter 2 [SGLT2] inhibitor) on CV and all-cause mortality and hospitalization for heart failure without any effects on classic atherothrombotic events is puzzling. More puzzling is that the curves for heart failure hospitalization, renal outcomes, and CV mortality begin to separate widely within 3 months and are maintained for >3 years. Modest improvements in glycemic, lipid, or blood pressure control unlikely contributed significantly to the beneficial cardiorenal outcomes within 3 months. Other known effects of SGLT2 inhibitors on visceral adiposity, vascular endothelium, natriuresis, and neurohormonal mechanisms are also unlikely major contributors to the CV/renal benefits. We postulate that the cardiorenal benefits of empagliflozin are due to a shift in myocardial and renal fuel metabolism away from fat and glucose oxidation, which are energy inefficient in the setting of the type 2 diabetic heart and kidney, toward an energy-efficient super fuel like ketone bodies, which improve myocardial/renal work efficiency and function. Even small beneficial changes in energetics minute to minute translate into large differences in efficiency, and improved cardiorenal outcomes over weeks to months continue to be sustained. Well-planned physiologic and imaging studies need to be done to characterize fuel energetics-based mechanisms for the CV/renal benefits.
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            Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations.

            Despite growing evidence that bariatric/metabolic surgery powerfully improves type 2 diabetes (T2D), existing diabetes treatment algorithms do not include surgical options.
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              Diabetes in Asia and the Pacific: Implications for the Global Epidemic.

              The last three decades have witnessed an epidemic rise in the number of people with diabetes, especially type 2 diabetes, and particularly in developing countries, where more than 80% of the people with diabetes live. The rise of type 2 diabetes in South Asia is estimated to be more than 150% between 2000 and 2035. Although aging, urbanization, and associated lifestyle changes are the major determinants for the rapid increase, an adverse intrauterine environment and the resulting epigenetic changes could also contribute in many developing countries. The International Diabetes Federation estimated that there were 382 million people with diabetes in 2013, a number surpassing its earlier predictions. More than 60% of the people with diabetes live in Asia, with almost one-half in China and India combined. The Western Pacific, the world's most populous region, has more than 138.2 million people with diabetes, and the number may rise to 201.8 million by 2035. The scenario poses huge social and economic problems to most nations in the region and could impede national and, indeed, global development. More action is required to understand the drivers of the epidemic to provide a rationale for prevention strategies to address the rising global public health "tsunami." Unless drastic steps are taken through national prevention programs to curb the escalating trends in all of the countries, the social, economic, and health care challenges are likely to be insurmountable.

                Author and article information

                Diabetes Care
                Diabetes Care
                Diabetes Care
                Diabetes Care
                American Diabetes Association
                January 2017
                20 December 2016
                : 40
                : 1
                : 3-6
                1Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA
                2Manchester Diabetes Centre, University of Manchester, Manchester, UK
                3Department of Pediatrics, Yale University School of Medicine, New Haven, CT
                4ISLHD, Wollongong, New South Wales, Australia
                5Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY
                6Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
                7Departments of Nutrition and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
                8ASH Comprehensive Hypertension Center, Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Chicago Medicine, Chicago, IL
                9Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
                10Dallas Diabetes Research Center at Medical City, Dallas, TX
                11Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA
                12Joslin Diabetes Center, Harvard Medical School, Boston, MA
                13Ochsner Diabetes Clinical Research Unit, Frank Riddick Diabetes Institute, Department of Endocrinology, Ochsner Medical Center, New Orleans, LA
                14Indiana University School of Medicine, Indianapolis, IN
                15Department of Public Health Sciences, University of Virginia, Charlottesville, VA
                16Division of Endocrinology, Diabetes and Metabolism, Duke University, Durham, NC
                17American Diabetes Association, Indianapolis, IN
                18Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR
                Author notes
                Corresponding author: William T. Cefalu, cefaluwt@ 123456pbrc.edu .
                © 2017 by the American Diabetes Association.

                Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at http://www.diabetesjournals.org/content/license.

                Page count
                Pages: 4
                Funded by: National Institutes of Health, DOI 10.13039/100000002;
                Award ID: 1U54-GM-104940, which funds the Louisiana Clinical
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