There are Doubtless Many Different Languages in the World, and None is without Meaning (1 Corinthians 14:10).

Latest decade, diversity and inclusion became common words for our future society. It is also applicable in science, biology, and medicine, not only in career making or opportunity for youth but the concepts of pathophysiology. It has been well accepted that atherosclerosis is a major risk for cardiovascular event and high glucose, hyperinsulinemia or insulin resistance state are the risk for atherosclerosis. Based upon those well-accepted ideas, many laboratory exams had been developed to evaluate atherosclerosis by noninvasive methods, such as carotid ultrasound ( for morphological change, pulse wave velocity, cardio ankle vascular index, and flow mediated vasodilation (FMD) for functional tests. As for carotid ultrasound intima-media thickness (IMT), carotid artery diameter (CAD), resistance index (RI) or pulsatility index (PI) have been developed and widely used clinically. The clinical implications of those parameters diverse, IMT is regarded as a general marker for atherosclerosis; on the other hand, CAD is a marker for vascular remodeling. RI indicates the vascular resistance of interest portion of vessel and PI reflects vascular resistance of distal portion of the vessel. The risk for stroke or cardiac events associated with IMT in nonlinear fashion [1) ] , and in the recent guideline of the Japanese societies besides Diabetes Association recommend IMT to screen for atherosclerosis in hypertensives. On the contrary European or the US guidelines do not recommend the routine use of IMT for the evaluation of atherosclerosis [4) ] . It is because the lack of standardization regarding the measurement of IMT and its high variability and low reproducibility raised concerns and addition of IMT to classical risk score failed to show advantages in predicting future cardiovascular disease [5) ] . Why not in diabetic patients who are very high in risks for atherosclerosis?

The recent study by Sasaki N et al [6) ] examined the impact of glucose metabolism in IMT, CAD, RI, and PI. Their cross-sectional large scale observational study revealed after adjustment for the confounding factors, CAD, RI, and PI but not IMT correlates with glucose metabolism parameters, such as HOMA-IR or insulin level, after glucose tolerance test. This study is a cross-sectional study, and cause and relationships are not discussed, however, this study implies ultrasound findings of vasculature is so diverse and should not be unified in one category of risk evaluation. In clinical setting, when we evaluate diabetic patients, we should recognize and appreciate their limitation of exams and benefit, and interpret the data with careful consideration of the physiological meaning of the tests.

The therapy for diabetes does not necessarily prevent cardiovascular event although the targeted blood glucose levels were equivalent. Formerly most prominent benefit were obtained in the class of drug that can reverse insulin resistance state, but recently SGLT2 inhibitors and GLP-1 agonists also showed cardioprotective effects but their mechanisms are not fully elucidated. This article raised several clinical and basic questions if those agents alter each atherosclerotic marker differently.

Laboratory exams have their own distinct characters and no two are the same. We appreciate wide variety of tools to evaluate patients.

Conflicts of Interest

None.