The expanding world of diabetes in this month's JCTE.

Many endocrinologists thrive on the expansive nature of endocrine disease. However, sometimes it feels like clinical endocrinology is dominated by diabetes. Understandably, since diabetes is arguably the most common endocrine disease, certainly time-consuming and expensive, and apparently at no risk of abating. This issue of JCTE is nominally focused on diabetes. However, the work of diabetes is ever-growing. So, clinically and translationally interested endocrinologists will notice that even when “focused” on diabetes, it is hard to avoid a theme of expansion.

There is a broad swath of diabetic issues covered, from basic science and epidemiology to clinical observation. Demonstrating the necessarily expansive nature of our approach to the epidemic of diabetes, articles in this issue address epidemiology, social science, dentistry, nephrology, podiatry, nutrition, and metabolism. Demonstrating the global and universal reach of diabetes, articles in this issue come from the United States – with high representation in ethnic and racial minorities, and internationally from Finland, Germany, Singapore, and the Pacific Islands.

Across this broad array of studies focused on diabetes, it is interesting that each approach reported in this issue – epidemiological, social, nutritional, clinical – come to strong conclusions that should enable further study or change our clinical approach and knowledge base. Epitomizing the international scope and the need to keep an expansive open mind, a paper from Gujral, collaborating with colleagues at Emory and the CDC in Atlanta as well as investigators from Chennai demonstrate that there is certainly more than one “flavor” to prediabetes and type 2 diabetes [1]. It is highly accepted that the pathophysiologic basis of type 2 diabetes typically requires both insulin resistance and relative beta-cell insufficiency. Using data from American and South Asian databases, they demonstrate that both groups are at very high risk for prediabetes and diabetes, but there is a striking susceptibility to beta-cell dysfunction in the South Asian population compared to American populations across different ethnicities, which may account for the higher rate of diabetes in South Asians. In other words, at least two different pathways to diabetes must be considered – one epitomized by early insulin resistance and the other by early beta-cell dysfunction, though both requiring some combination of the two to lead to eventual type 2 diabetes. One must keep an expansive open mind to understand there are more than one pathways to type 2 diabetes.