The Role of Diabetes Care andIts Contributions to the Field ofDiabetes: A Profile in ProgressDiabetes Care 2018;41:241–249 | https://doi.org/10.2337/dci17-0021
Progress in the field of diabetes comesfrommany sources, including novel ideas,research breakthroughs, expanding ther-apeutic options, technological advances,charismatic personalities, and enhancedcommunication between the scientificand clinical communities. It is in the latterrealm that the American Diabetes Associ-ation’s (ADA’s) journal Diabetes Care hasplayed an increasingly important rolesince its founding in 1978. Through theyears, the journal has grown to becomeboth a locus for and stimulus of all theother sources of progress in diabetes clin-ical research and care. From its inauguralyear, during which there were concernsabout how to fill six issues and an accep-tance rate just under50%(1), to its present41st volume year, with monthly issues;3,000 submissions annually, and an ac-ceptance rate for original articles of under10%, Diabetes Care has emerged as thepremier journal in its field.
The Start of Something Big
The 1970s were a busy time in diabetesresearch that ushered in numerous trans-formative advances, supported by amarked increase in research fundingfrom the National Institutes of Health(NIH) (2). The role and influence of theADA were also broadening to include agreater focus on patient care, nursingpractice, health care delivery, and profes-sional education (3). Against this back-drop, ADA professional members began
to wonder whether the association’sjournalDiabetes (established in 1952) ad-equately addressed the needs of clinicalinvestigators and clinicians treatingpatients with the disease. A committeeappointed to study the question com-missioned a physician survey that con-firmed strong interest in a clinicallyoriented diabetes journal. Soon thereaf-ter, Diabetes Carewas launched. The sec-ond word of its title was an acronym forits focus on Clinical and Applied Researchand Education (2).
In the 40 years since, annual submis-sions have increased more than 17-fold,the number of published articles hasgrown by more than 9-fold, and total pa-ges have expanded more than 10-fold(Fig. 1). This growth reflects not only theincrease in diabetes prevalence to epidemiclevels worldwide, but also the journal’swell-deserved reputation as a prestigiousvenue for publishing in the field of diabetesclinical care.
More important than the quantitativeevidence forDiabetes Care’s characteriza-tion as a “Profile in Progress,” however, isthe qualitative development of its con-tents and the ways in which it has influ-enced the course of diabetes clinicalresearch and care. One way such influ-ence is estimated is through a journal’simpact factor. Impact factors are usedto gauge the importance of a journalbased on how frequently its articles arecited in the wider literature. Table 1 lists
the annual impact factors for DiabetesCare, starting with the earliest availableimpact factor of 3.148 in 1991. The mostrecent impact factor of 11.857 for 2016 isthe highest ever achieved by an ADA jour-nal, giving Diabetes Care the rank of fifthamong 138 rated endocrinology and me-tabolism journals and making it the top-ranked and most-cited journal devotedexclusively to diabetes.
Much of this success can be attributedto the vision and dedication of the ninemen who have served as the journal’seditors in chief through the years (whoareprofiled in Fig. 2), aswell as their teamsof associate editors. Credit is also due tothe many scientists and clinicians whohave submitted their research and servedas reviewers.
Tobetter explain the steady rise in stat-ure and influence of Diabetes Care overtime, we provide below a discussion ofsome of the key articles published ineach decade. These articles, though sub-jectively selected, illustrate the breadth,diversity, maturation, and increased sci-entific rigor with which Diabetes Carehas contributed to the dialogue betweenresearchers and diabetes care providersthrough the years.
1970s: Off and Running
The 1970s saw numerous advances in thefield of diabetes, including the develop-ment of purified insulin and the first in-sulin pump, the advent of self-monitoring
1American Diabetes Association, Indianapolis, IN2Case Western Reserve University, Cleveland, OH
of blood glucose (SMBG), the widespreaduse of A1C testing, the emergence of spe-cialized diabetes educators, and theascent of the multidisciplinary team ap-proach to clinical care. From its inceptionin 1978, Diabetes Care focused on pub-lishing peer-reviewed articles on suchtopics (2).Among the articles in its first issue (Fig.
3) were a research report on the glycemiceffects of jet-injected insulin (4), a reviewof glycemic management in pregnancycomplicated by diabetes (5), and an earlydescription of pancreas transplantation(6). Later that year, an article translatedfrom French and reprinted in two partsfrom Diabete et Metabolisme (7,8) pro-vided impressive albeit somewhat crudeevidence suggesting that better glycemiccontrol might reduce the long-term com-plications of diabetes. By the end of itsfirst year, Diabetes Care had been se-lected for inclusion in Index Medicus andthe MEDLARS online database (1).In 1979, the journal published prelimi-
nary results of continuous pump-infusedsubcutaneous insulin for type 1 diabetes(9), an introduction to A1C testing to doc-ument chronic hyperglycemia in children(10), and an articlewritten by an engineerwith type 1 diabetes who had used anearly glucose meter throughout the de-cade and developed several refinementsin technique to improve the utility ofSMBG (11).Although such early reports often in-
volved small numbers of individuals,they served to alert physicians, nurses,and other professionals on the frontlinesabout treatment innovations that wouldeventually benefit countless patients. The
contents of the first two volumes of Di-abetes Care attest to its editorial team’sintention to position the journal on theleading edge of progress.
1980s: Insulin Therapy and DiabetesSelf-management
By the early 1980s, submissions were onthe rise, and in 1988, the publication ex-panded to 10 issues per year. Its contentsin this decade reflected growing interestin improving the efficacy and safety ofinsulin therapy, encouraging the prolifer-ation of SMBG, and supporting patientself-management more broadly.
In 1980, the journal published the pro-ceedings of the Kroc Foundation Interna-tional Conference on Insulin DeliveryDevices (12), an expert workshop explor-ing the potential for development ofnovel insulin delivery devices, includingimproved pumps, an artificial pancreassystem, and a fully implantable deliverydevice. The conference chairman empha-sized that progress in insulin administra-tion must occur in tandem with progressin the monitoring of glycemic control. To-ward that end, the journal that year alsopublished an international symposium onhome blood glucose monitoring that ex-amined the accuracy and costs of variousmethodsof SMBGandmarkedanewera inwhich tight glycemic control “will be bothvalid and achievable to a degree not be-fore approximated except for the briefesttime. . . in a laboratory setting” (13).
By mid-decade, five glucose meterswere available for home use, and an arti-cle of great practical application com-pared the accuracy, ease of use, costs,and availability of supplies for each,
summarizing the advantages and disadvan-tages clinicians should considerbeforemak-ing recommendations to their patients (14).
As intensive insulin therapy becamemore common, concerns about hypogly-cemia increased. A 1983 reviewdescribedsophisticated studies of hypoglyce-mia and its counterregulation (15), anda 1985 original report examined thefrequency, causes, and prevention of hy-poglycemia, drawing attention to thedangers of this acute complication andthe need for better patient educationabout its treatment and prevention (16).The journal also published articles elu-cidating the benefits of insulin in type 2diabetes, including an early report on thereversal of insulin resistance through in-sulin therapy (17).
Diabetes Care also encouraged greaterscientific rigor in fields such as behavioralmodification and education. A 1983 reportof a randomized trial comparing group andindividual nutritional counseling exemplified
Table 1—Diabetes Care impact factorsand citations per year, 1991–2016
Impactfactor*
Totalcitations
1991 3.148 NA
1992 4.026 NA
1993 3.164 NA
1994 2.755 NA
1995 2.526 NA
1996 3.457 NA
1997 3.321 9,186
1998 4.180 11,063
1999 5.076 12,409
2000 4.992 13,191
2001 5.404 15,394
2002 5.477 15,982
2003 7.501 21,164
2004 7.071 23,635
2005 7.844 27,563
2006 7.912 30,486
2007 7.851 35,824
2008 7.349 40,826
2009 6.718 43,007
2010 7.141 42,325
2011 8.087 44,452
2012 7.735 49,025
2013 8.570 52,771
2014 8.420 56,103
2015 8.934 60,339
2016 11.857 66,107
*Impact factors are based on the previous2 years’ citations and first became availablefor Diabetes Care in 1991. NA, not available.
Figure 1—Number of articles published, articles submitted, and printed pages for selected years,1978–2013.
242 Profiles in Progress Diabetes Care Volume 41, February 2018
this, using objective measures of met-abolic outcomes and changes in bodyweight to evaluate differences be-tween the two approaches (18). Asmore emphasis was placed on patient
self-management, the journal also pub-lished criteria for validating tests of patients’knowledge (19) and an assessment ofdiabetes-related knowledge among thenurses charged with their care and
education (20). Meanwhile, readers werekept well informed on advances in basicscience through reviews on topics such asC-peptide (21) and the pathophysiologyof insulin secretion (22).
In 1987, theDiabetes Control and Com-plications Trial (DCCT) investigators choseto submit the critical results of their feasi-bility trial toDiabetes Care (23). Their datademonstrated that type 1 diabetes
patients could be randomly assignedto an intensive or standard treatmentregimen and maintain glucose levels farenough apart to determine whether reti-nopathy would develop or progress more
slowly with intensive treatment and atwhat clinical cost. Although the mainDCCT results were published 6 years laterin a journalwith broader readership, 51ofthe 259 subsequent articles from this
Figure 2—Continued.
244 Profiles in Progress Diabetes Care Volume 41, February 2018
landmark trial have appeared in DiabetesCare. Most important among them wasthe 2016 follow-up report demonstratingthat, over 28 years, mortality in the trial’sintensively managed cohort did not differsignificantly from that in amatched groupwithout diabetes (24).June of 1989 brought an important new
feature to the journal: the first edition ofADA’s Standards of Care position state-ment (25); in January 1990, the journalalso began publishing an annual compen-diumof current ADAposition and consen-sus statements collectively known as theClinical Practice Recommendations. Up-dated annually or as needed by the ADAProfessional Practice Committee, thesepublications have been among the mostauthoritative and influential evidence-based guidelines for diabetes manage-ment in the world. In recent years, theyhave been consolidated into a single, co-hesive, multiple-chapter supplement, the
most recent of which was published inJanuary (26).
Throughout its first full decade, Diabe-tes Care helped to opened the door tobetter understanding of the pathophysi-ology of diabetes, the benefits of SMBG,themechanisms of insulin action, and thecomplex relationship between glucoseand insulin. The diabetes communitywas learning more about hyperglycemiaand its associationwith long-term compli-cations, and the journal was at the fore-front of disseminating this knowledge.
1990s: New Insights and Therapiesfor a Worldwide Epidemic
In 1990, Diabetes Care began producing12 issues per year. Early in the decade, thejournal published a definitive descrip-tion of insulin resistance syndrome,whichincludes a cluster of metabolic disorders(diabetes, dyslipidemia, hypertension,and cardiovascular risk), that highlighted
the need to define the mechanismsresponsible for the defect in insulin-mediated glucose metabolism (27). At theend of the decade, the journal publisheda report on a novel method for estimatingwhole-body insulin sensitivity that was sim-ple to calculate and provided a credible ap-proximation from data obtained via oralglucose tolerance testing (28).
In addition to pathophysiology, the dia-betes community at that time was also fo-cused on epidemiology and prevention. In1993, the journal published an article onstandardized global estimates of the preva-lence of abnormal glucose tolerance inadults (29). The information in that article,basedonsurveyscollected from75commu-nities in 32 countries, provided the firstcomparable data on rates of diabetes andimpaired glucose tolerance (IGT) aroundthe world. A later report estimated futurediabetes prevalence worldwide and sup-ported earlier predictions of epidemic ex-pansion of the disease through the firstquarter of the 21st century (30). These ar-ticles were a call to action on the urgentpriority of diabetes prevention.
Other groundbreaking reports also hadmajor implications for the prevention oftype 2 diabetes and its long-term conse-quences. The 1993 MRFIT (Multiple RiskFactor Intervention Trial), an early, large,12-year cardiovascular risk study in men,confirmeddiabetesasa strong independentrisk factor for cardiovascular mortality be-yond the effects of elevated cholesterol, hy-pertension, and smoking (31). In 1997, thejournal published the results of the firstlarge-scale, controlled trial of lifestyle in-tervention for type2diabetes prevention.The groundbreaking Da Qing IGT and Di-abetes Study (32) showed that dietarymodification, exercise, or both reducedthe development of diabetes comparedwith a control condition of no interven-tion in high-risk Chinese adults with IGT.This was the first of numerous trials con-ductedaroundtheworld thatdemonstratedthe viability of lifestylemodification and var-ious pharmacological interventions forpreventing type 2 diabetes.
The 1990s also marked the beginningof a rapid expansion of the diabetes ar-mamentarium, and the proliferation ofnew drugs and new drug classes waschronicled in the journal (33–36), includ-ing descriptions of the efficacy of metfor-min (34) and a report on the efficacy andsafety of glimepiride, a modern sulfonyl-urea that has since become a widely used
Figure 3—Inaugural issue of Diabetes Care, January/February 1978.
treatment option (35). As new drug de-velopment gained momentum, the needfor accurate blood glucose monitoringbecame even more crucial, especially withregard to detecting hypoglycemia, and thisissue was also addressed (36–38).The rising cost of treating diabetes was
not lost on the editors of Diabetes Care.Having earlier taken up the issue of insur-ance reimbursement for diabetes educa-tion and therapeutic technologies (39),they continued to focus on the economicsof diabetes. One article used computermodeling to estimate that the federalgovernment savednearly $250million an-nually and nearly 54,000 person-years ofsight by providing preventive eye care tothe 60% of people with type 2 diabeteswho at that time received such services(40). It further estimated that reaching allpatients would save more than $472 mil-lion and .94,000 patient-years of sight(40). Such articles had important implica-tions for health care reform.
2000s: Progress on Many Fronts
Thefirst decadeof themillenniumbroughtrefinements to clinical research, advancesin therapeutics, and a focus on diabetesdiagnosis and epidemiology. In 2000, thejournal published important evidencesupporting HOMA of insulin sensitivityas a reliable surrogate for in vivo mea-surement in humans (41). A later articlefurther clarified the strengths and weak-nesses of this method (42), which is nowwidely used to determine insulin sensitivityandb-cell function in large-scale trials.Di-abetes Care continued to publish articlesabout pharmacotherapeutic advances, in-cluding the influential Treat-to-TargetTrial ofbasal insulin replacement inpatientswith type 2 diabetes inadequately con-trolled with oral agents, which presenteda simple, basal-only regimen that facili-tated the earlier initiation of insulin ther-apy for patients with type 2 diabetes (43).Other articles kept readers apprised ofemerging oral agents such as pioglitazone(44) andnewdrug classes such as dipeptidylpeptidase 4 (DPP-4) inhibitors (45,46).Several epidemiologic studies under-
scoredgrowingconcernsabout thediabetesepidemic and the rising costs of diabetes, aswell as the need for health care policies toaddress them. A 2001 article projected adramatic increase in the burden of diabe-tes in the U.S. through 2050 (47). Addi-tional articles published from the late1990s and into the 2000s further
demonstrated that glycemic controlcould be improved in underserved or dis-advantaged patients at high risk for com-plications and discussed how imbalancesin access to care, medication adherence,and education, as well as clinical inertia,contribute to poor clinical outcomes(48–50). Interest in diabetes during preg-nancy was also increasing, as reflected ina 2002 review of the link between gesta-tional diabetes mellitus (GDM) and laterdevelopment of type 2 diabetes (51), a2008 report on trends in preexisting di-abetes and GDM (52), and another 2008report examining the possibly protectiveeffects of insulin therapy during preg-nancy on the fetal vascular system (53).
The practical application of research inclinical practice continued to be a key fo-cus for the journal. A 2005 review on thediagnosis, prevention, and treatment ofnephropathy in diabetes (54), still widelycited today, raised awareness of earlyscreening and diagnosis methods andoutlined therapeutic strategies for reno-and cardioprotection in high-risk patients.Other articles provided practical informa-tion on new treatments for complicationssuch as neuropathic foot ulcers (55,56)and erectile dysfunction (57). A 2008systematic tabulation of data on the gly-cemic index and glycemic load values ofnearly2,500 foodsbecameauseful resourcefor researchers and clinicians alike (58).
Over time,Diabetes Care became a keyvenue for articles reporting on the designand resultsof important randomizedclinicaltrials (59–61), allowing readers the oppor-tunity to anticipate progress and judgethe value of emerging interventions.
The final year of this decade broughtanother influential paper to the journal:the consensus report of an internationalexpert committee convened by ADA, theEuropean Association for the Study ofDiabetes (EASD), and the InternationalDiabetes Federation (IDF) to considercurrent and futuremethods of diagnosingdiabetes (62). The committee’s recom-mendations favoring the use of the A1Cassay for diagnosis appeared in DiabetesCare in 2009 (62) and were adopted inthe following year’s ADA Clinical PracticeRecommendations (63).
2010 to the Present: Building on aTradition of Excellence
Now in its fourth decade, Diabetes Carehas continued to innovate by introducingseveral new programs and features to
provide readers with a more holistic,big-picture view of key topics in clinicalresearch and care.
June 2012 marked the first of whatwould become an annual Diabetes CareSymposium, held in conjunction withADA’s Scientific Sessions. These signatureevents are among the most well-attendedprogramsateachyear’smeeting,withpre-sentations representing landmark trialsand innovative clinical and translationalstudies that challenge current paradigmsof diabetes treatment or present evolvingmanagement strategies. The most recentsymposium, in June 2017, featured fourworld-renowned experts (including thefounding and current editors of the journal)who were invited to present their views onthe current status and future develop-ment of diabetes management, with anemphasis on cardiovascular disease.
Diabetes Care Editors’ Expert Forumsare another relatively recent addition tothe journal. For these programs, the jour-nal convenes an expert panel to discuss atimely topic in diabetes clinical manage-ment and then publishes a paper reflect-ing the consensus viewpoints emergingfrom the forum. The most recent forum,on the topic of cardiovascular outcomestrials (CVOTs) in type 2 diabetes, waspublished in the January 2018 issue ofDiabetes Care and provides a comprehen-sive review of completed and ongoingCVOTs and recommendations for enhanc-ing the value of future trials (64).
In 2013, the journal launched anothernovel feature: special-topic article collec-tions. The first such collection featuredarticles from the TODAY (Treatment Op-tions for type 2 Diabetes in Adolescentsand Youth) study providing data on theefficacy and safety of treatment, as wellas the rate of complications and the pro-gression of risk factors, in the growingpopulation of youth with type 2 diabetes(65). Table 2 contains a list of theDiabetesCare symposiums, expert forums, andspecial-topic collections to date.
In addition to these innovative proj-ects, the journal has continued its tradi-tion of publishing outstanding researchwith an emphasis on novel conceptsand emerging treatments. A 2010 metaa-nalysis, for example, reported on a newdietary risk factor for diabetes, show-ing that greater consumption of sugar-sweetened beverages is associated withnot only weight gain and increased obesityrisk, but also higher risks for metabolic
246 Profiles in Progress Diabetes Care Volume 41, February 2018
syndrome and type 2 diabetes (66). In2011, a report from the Look AHEAD(Action for Health in Diabetes) studyprovided strong evidence of significantimprovement in cardiovascular diseaserisk factors from modest weight loss(67). And in 2014, an interesting reviewarticle summarized available evidence onthe challenges faced by people with dia-betes who want to participate in physicalactivities at high altitude (68).The journal also continued to highlight
newprocedures and technological advan-ces. A 2012 article described trends in theprimary efficacy and safety outcomes ofislet transplantation in people with type 1diabetes (69). In 2014, the journal pub-lished results of the first randomizedcrossover trials of a wearable artificialpancreas system (70), as well as a trial ofclosed-loop glucagon delivery to preventhypoglycemia in type 1 diabetes (71). In
2013, an expert point-counterpoint dis-cussion presented arguments for andagainst the use of incretin-based thera-pies, given conflicting safety data avail-able at the time (72,73). The impact ofintensive insulin treatment on the preser-vation of b-cell function was highlightedin studies reported in 2012 in patientswith newly diagnosed type 2 diabetes(74) and in 2013 in patients with new-onset type 1 diabetes (75). Recent reviewarticles have included a summary of dataon natriuretic peptides (76), a history ofhyperosmolar hyperglycemic state (77),and an update on the effects of DPP-4 in-hibition onmicrovascular complications (78).
As noted earlier, the articles includedin this narrative are by no means ex-haustive, nor were they selected in anyobjective manner. Rather, they werementioned as outstanding examples ofthe high-quality research and information
disseminated by Diabetes Care through-out the past 40 years and as evidence of thejournal’s crucial and ongoing role in facili-tating progress in diabetes clinical researchand care.Moreover, the contents ofDiabe-tes Care fully reflect the history of diabe-tes itself over the same period of time.
Acknowledgments.The authors thank ChandraBlazek, Case Western Reserve University, Cleve-land, OH, for administrative assistance; HeatherNorton Blackburn and Christian S. Kohler, Amer-ican Diabetes Association, Arlington, VA, forassistance with research and review of themanuscript; Jay S. Skyler, University of MiamiLeonard M. Miller School of Medicine, Miami,FL, former editor in chief of Diabetes Care, forsharing knowledge of the history of the journal;and all the former and current editors of Di-abetes Care, who provided input and helpfuladvice. Editorial services for this article were pro-vided by Debbie Kendall, Kendall Editorial, Rich-mond, VA.
Table 2—Diabetes Care Symposiums, Editors’ Expert Forums, and special-topic article collections
Issue of publication
Diabetes Care Symposiums“Innovative Concepts and Evolving Clinical Management Strategies in Diabetes Care” July 2012“Innovative Studies That Challenge Current Paradigms of Diabetes Treatments” July 2013“New Drug Therapies, Innovative Management Strategies, and Novel Drug Targets” July 2014“Novel Clinical Interventions in Therapy That Impact the Management of Diabetes” July 2015“Novel Clinical Strategies in the Management of Diabetes” July 2016“Diabetes Research and Care Through the Ages” September 2017
Diabetes Care Editors’ Expert Forums“PersonalizedManagement of Hyperglycemia in Type 2Diabetes: Reflections FromaDiabetes Care Editors’ Expert Forum” June 2013“Insulin Therapy in People With Type 2 Diabetes: Opportunities and Challenges? June 2014“Beyond Metformin: Safety Considerations in the Decision-Making Process for Selecting a Second Medication for Type 2
Diabetes Management: Reflections From a Diabetes Care Editors’ Expert Forum” September 2014“Advances in the Science, Treatment, and Prevention of the Disease of Obesity: Reflections from a Diabetes Care Editors’
Expert Forum” August 2015“Update and Next Steps for Real-World Translation of Interventions for Type 2 Diabetes Prevention: Reflections from
a Diabetes Care Editors’ Expert Forum” July 2016“Cardiovascular Outcomes Trials in Type 2 Diabetes: Where Do We Go From Here? Reflections from a Diabetes Care
Editors’ Expert Forum” January 2018
Special-topic article collections“TODAY Study: The Changing ‘Face’ of the Type 2 Diabetes Epidemic” June 2013“A Critical Review of the Risks and Benefits of Incretin-Based Therapies” July 2013“DCCT/EDIC 30th Anniversary Summary Findings” January 2014“Current Concepts of Type 2 Diabetes Prevention” April 2014“Advances in Artificial Pancreas Development” May 2014“Understanding and Addressing Health Disparities in Diabetes Care and Research” February 2015“Evolving Tactics With Inhibition of Sodium–Glucose Cotransporters” March 2015“Type 1 Diabetes at a Crossroads” June 2015“Guiding Principles for Diabetes Care” October 2015“Insulin After More Than 90 Years . . . We Have Come a Long Way!” December 2015“IDF-ADA Symposium: Translational Diabetes Research With Immediate Clinical Impact” January 2016“Considerations in the Management of Gestational Diabetes Mellitus” January 2016“Cardiovascular Diseases and Diabetes” May 2016“Metabolic Surgery and the Changing Landscape for Diabetes Care” June 2016“The Artificial Pancreas in 2016: A Digital Treatment Ecosystem for Diabetes” July 2016“Emerging Science, Concepts, and Approach to Precision Medicine” November 2016“Psychosocial Research and Care in Diabetes” December 2016“Emerging Science and Concepts for Management of Diabetes and Aging” April 2017“Continuous Glucose Monitoring and Risk of Hypoglycemia” December 2017
Duality of Interest. L.R. is an employee of theAmerican Diabetes Association, which publishesDiabetes Care. No other potential conflicts of in-terest relevant to this article were reported.
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