Current guidelines have not implemented data that speaks to protective factors for diabetes complications.
Complications of diabetes are responsible for most of the morbidity and mortality associated with the disease. In addition, the societal and financial costs related to diabetes are also mainly associated with the onset and treatment of these complications. Traditionally, chronic complications of diabetes have been classified into either macrovascular disease, which includes cardiovascular disease (CVD), or microvascular disease, which includes retinopathy (DR), nephropathy (DN), and neuropathy. However, it is clear that this artificial classification needs to be revised since there are many complications of diabetes that cannot be easily or correctly placed in only the microvascular or macrovascular categories. For instance, neuropathy is thought to be caused by both microvascular and neuronal/axonal cell dysfunction.

Practitioners may not be familiar with these protective factors. While traditional pathways that protect many tissues—such as the role of insulin, growth factors, and antioxidant pathways—have already been established in the literature, recent findings from unique clinical cohorts, like the Medalists, have enabled a better and deeper understanding of previously unknown phenomena, such as the novel protective roles played by RBP3 and the glycolytic and TCA cycles in DR and DN, respectively. Despite hyperglycemia being the main metabolic feature in diabetes, insulin resistance, altered insulin signaling, and dyslipidemia, the availability of new drugs with multiple mechanisms of action, such as SGLT2 inhibitors and GLP-1R agonists, has increased therapeutic options for patients, and suggests that there are unknown pathways that can protect different organs from being damaged by the metabolic stresses of diabetes. 

In addition, there are race/ethnicity nuances to these protective factors not known in the general medical community yet. Asian Americans are 40 percent more likely to be diagnosed with diabetes than non-Hispanic whites.
In 2017, Asian Americans were 60 percent more likely to be diagnosed with end-stage renal disease than non-Hispanic whites. From 2017-2018, Asian Indians were 70 percent more likely to be diagnosed with diabetes, as compared to non-Hispanic whites. There is a need for clinicians to stay abreast of novel approaches to optimize the care of patients with diabetes by assessing the protective factors of diabetes complications.