Where diabetes is rising fastest, the evidence is quietest: Why <scp>LMIC</scp> authorship matters

Abstract

Diabetes is now a truly global condition, with the most rapid increases in prevalence occurring in low- and middle-income countries (LMICs).1, 2 These regions face a convergence of demographic change, urbanisation, nutritional transition and constrained health systems, resulting in earlier onset of diabetes, high complication rates and substantial social and economic impact.1, 3, 4 Yet, despite bearing a growing share of the global burden, LMICs remain under-represented in the diabetes research literature.5-7 Other works have made similar observations. One such work is by Allen et al., who reported an imbalance in NCD research, often characterised by NCD publications led by authors from LMICs, published in lower-impact journals with lower citation rates than those led by authors from HICs.7 This imbalance matters not only for equity, but also for the relevance, applicability and quality of the global evidence base.1, 4, 8 Current estimates suggest that over 75% of people living with diabetes reside in LMICs, a proportion projected to increase further over the coming decades.9 The Lancet Commission on Diabetes has emphasised that transforming diabetes outcomes globally requires locally generated data that reflect diverse phenotypes, health systems and social contexts, rather than extrapolation from high-income settings alone.10 Similarly, the World Health Organization (WHO) and the International Diabetes Federation (IDF) have consistently highlighted the need for context-specific and domestic evidence to guide policy and practice in regions where health system capacity and resources differ markedly from those in HICs.1, 4 Despite this, the global diabetes evidence base remains dominated by research originating from HICs.5, 10 While such research is indispensable, over-reliance on evidence generated in well-resourced settings risks limiting the external validity of clinical guidelines, service delivery models and policy recommendations when applied in LMIC contexts.11-13 Differences in age of onset, multimorbidity patterns, workforce composition, access to diagnostics and therapies and health-care financing mechanisms all influence how diabetes is experienced and managed across settings.4, 5, 10, 14 Encouraging and supporting diabetes research in LMICs is therefore a scientific imperative, not simply a matter of representation.10, 12 Research conducted in LMICs offers unique and important insights. These include the connection between diabetes and infectious diseases, the impact of poverty, food insecurity and informal work on disease progression, and the development of new primary care and community-based models that use task shifting and the practical use of limited resources.10, 15, 16 Many of these approaches are becoming increasingly relevant to underserved populations in high-income countries (HICs), highlighting the global value of research led by LMICs and the importance of mutual learning.2, 17 Authorship is a key issue in this context. Academic recognition, research priorities, career advancement, funding opportunities and leadership roles are all influenced by authorship. Equitable authorship fosters research pertinent to local needs, interpretations informed by context and the development of enduring capabilities.18 Participation of researchers from LMICs in diabetes-related authorship remains significantly constrained, notwithstanding these challenges. These limitations encompass restricted access to financial support and allocated research time, insufficient research infrastructure, well-established and resourced libraries, and limited avenues for training in study design, statistical analysis and academic writing (Figure 1). Furthermore, language obstacles and publication expenses exacerbate these challenges.5, 6, 12 Structural inequities, inherent in international collaborations, can exacerbate the marginalisation of LMIC investigators; agenda-setting, senior authorship and corresponding authorship often reside within high-income country HIC institutions, which usually pay for the article processing costs as required by their institutions before payment can be made, even when the research is primarily conducted in LMIC settings, or led by authors from LMICs.5, 6, 12 These established patterns have been the subject of considerable investigation in international health research, potentially reinforcing knowledge creation practices that prioritise extraction over collaborative methodologies.12, 19 Significantly, rigorous peer review should prioritise scientific contribution and relevance over resource demands or adherence to high-income health system standards. Diabetic Medicine has consistently and uniquely demonstrated a dedication to publishing research that is both clinically pertinent and globally informed. As the epidemiology of diabetes continues to shift, there is both an opportunity and a responsibility to ensure that the voices shaping the evidence increasingly reflect the populations most affected. This includes early- and mid-career researchers, clinicians, nurses, patient advocates and allied health professionals working in LMIC settings, whose insights are central to real-world diabetes care but remain under-represented in the literature. If you're uncertain about the fit of your work, we encourage you to reach out to the journal early. Your insights are crucial for developing diabetes care that is both fair and effective globally. This project was not funded, but SS is supported by National Institute for Health Research Applied Research Collaboration East Midlands NIHR Global Research Centre for Multiple Long Term Conditions. The authors declare no conflicts of interest.