Interdisciplinary perspectives on diabetes and microcirculatory dysfunction: A global bibliometric analysis

Abstract

BACKGROUND

The prevalence of diabetes and its association with microcirculatory dysfunction presents a significant challenge in contemporary global health. Addressing this nexus is crucial for developing targeted therapeutic interventions.

AIM

To trace the progression and delineate the current state of interdisciplinary research concerning diabetes and microcirculation.

METHODS

Employing a bibliometric approach, this study scrutinizes 12886 peer-reviewed publications retrieved from the PubMed and Web of Science databases. The focus is on elucidating the research trajectory and thematic concentrations at the confluence of diabetes and microcirculation.

RESULTS

Research outputs have surged since 2011, with the United States, China, and the United Kingdom leading in the quantity and quality of publications. This analysis revealed that journals such as Diabetes Care and The New England Journal of Medicine, along with top research institutions, have significantly contributed to advancing the understanding of microvascular processes affected by diabetes. The central themes identified include inflammation, oxidative stress, and endothelial dysfunction, which are critical in mediating the microvascular complications of diabetes.

CONCLUSION

This bibliometric evaluation reveals an evolving landscape focusing on diabetes and microcirculatory dysfunction. The complexity of diabetic microvascular issues encouraged multidisciplinary research strategies that are imperative for global health outcomes.

Key Words: Diabetes mellitus; Microcirculatory dysfunction; Bibliometric analysis; Endothelial dysfunction; Diabetic complications

Core Tip: This bibliometric analysis elucidates the relationship between diabetes and microcirculation, spotlighting the central role of endothelial dysfunction in the pathophysiology of diabetes-related complications. Leveraging extensive datasets from PubMed and Web of Science Core Collection, our study traces the evolution of research from the foundational studies of the 1950s to contemporary explorations into microvascular responses under diabetic conditions. It reveals that endothelial disruption, influenced by oxidative stress and inflammatory pathways, significantly contributes to the microvascular complications prevalent in diabetes. The research reveals the need for advancements in non-invasive diagnostic technologies and targeted therapeutic strategies that address the microvascular aspects of diabetes.

INTRODUCTION

Diabetes mellitus, a complex endocrine disorder, is typified by persistent hyperglycemia, insulin resistance, and a deficiency in insulin production or function. The International Diabetes Federation reported a staggering increase in the global prevalence of this disease among adults aged 20 to 79 years - from 8.3% (approximately 382 million) in 2013 to 425 million in 2018. By 2021, an even more alarming figure emerged, with impaired glucose tolerance affecting 529 million adults worldwide[1]. These statistics, while revealing, barely scratch the surface of the escalating public health crisis. Notwithstanding considerable advancements in diabetes research and therapeutic approaches, the incidence of morbidity, disability, and mortality attributable to diabetes remains on an upward trajectory[2]. It is imperative to recognize that much of the extant diabetes research has been myopic, fixating on isolated facets of the disease rather than embracing a holistic approach that acknowledges the intricate nexus of contributory factors to its pathogenesis and progression. A paradigm that shifts towards a comprehension of diabetes, encompassing its pathophysiology, risk determinants, and treatment modalities, is vital for ameliorating its management and mitigating its global health impact.

Microcirculation, the network of minute blood vessels including arterioles, venules, and capillaries with diameters less than 150 μm, is integral to the vascular system[3]. This microvascular bed, replete with red and white blood cells, and platelets, orchestrates a symphony of blood flow dynamics, cell-to-cell, and molecular-cell interactions[4]. As a cornerstone of physiological homeostasis, microcirculation facilitates the exchange of substances and signals between tissues and the systemic environment. This ensures that the delivery of critical nutrients and oxygen for cellular metabolism and the efficient eradication of metabolic byproducts. Accumulating evidence implicates microcirculatory dysfunction as a pivotal factor in the onset and progression of diabetes and its sequelae[5]. The microvascular perturbations characteristic of diabetes may precipitate compromised blood flow and oxygenation to tissues, fostering the pathogenesis of diabetic complications such as retinopathy, nephropathy, and neuropathy[6,7]. Additionally, microcirculatory dysfunction may potentiate insulin resistance[8], diminish glucose uptake[9], and provoke inflammation[10], all of which are hallmarks of diabetes. Hence, delineating the role of microcirculation in diabetes is instrumental for unveiling novel pathophysiological insights and therapeutic avenues.

The centenary of insulin's discovery in 2021 was commemorated through a series of critical reviews[11,12], reflecting on its profound impact on diabetes management and public health. This milestone, however, also highlights the relentless nature of diabetes as an ongoing global health challenge. While insulin therapy has revolutionized treatment paradigms, saving countless lives and markedly enhancing the quality of life for those afflicted, diabetes remains a formidable burden on individuals and health systems worldwide. In response to this enduring challenge, our research employs bibliometric analysis to elucidate the complex interactions between diabetes and microcirculation. By focusing on a detailed examination of primary research articles that address these interactions from a microlevel perspective, our study contributes to a more comprehensive understanding of the microvascular complications associated with diabetes. This, in turn, is intended to drive further academic inquiry and advance the development of precise therapeutic interventions targeting these specific aspects of the disease, thereby refining patient outcomes and alleviating the broader public health burden.

MATERIALS AND METHODS

Search strategies

To systematically review the literature, we exclusively employed PubMed (https://pubmed.ncbi.nlm.nih.gov/) and the Web of Science Core Collection (WoSCC; https://www.webofscience.com/wos/woscc/) due to their comprehensive coverage in biomedical and life sciences literature. We designed the search queries to incorporate both broad and specific terms relevant to our study objectives. Specifically, the search syntax included combinations of terms related to diabetes and microvascular complications as follows: In WoSCC: ((TS = (diabetes)) AND ((TS = (microcirculation)) OR TS = (microvascular))); In PubMed: "diabetes"[Title/Abstract] AND ("microcirculation"[Title/Abstract] OR "microvascular"[Title/Abstract]).

We restricted our search to English-language articles published up to December 31, 2023. This strategy yielded a total of 11357 records in WoSCC and 9042 in PubMed (Figure 1; Supplementary material).

Figure 1 Systematic search and selection flowchart. This flowchart delineates the systematic process adopted in our study, divided into three sequential stages: Identification, purification, and bibliometric analysis and visualization. The identification stage involved a comprehensive search of original articles written in English from inception until December 31, 2023, using the search criteria (TS = (diabetes)) AND (TS = (microcirculation) OR TS = (microvascular)). This search yielded 11357 and 9042 publications from Web of Science Core Collection (WoSCC) and PubMed, respectively. During the purification stage, 6297 duplicate entries were removed from the PubMed dataset. Subsequently, two independent researchers scrutinized the remaining studies, excluding 936 and 280 studies from WoSCC and PubMed, respectively, that failed to meet predefined inclusion criteria. In the bibliometric analysis and visualization stage, the remaining 12886 original articles underwent detailed bibliometric analysis, encompassing aspects such as annual publication volumes, contributing countries/regions, institutions, journals, authors, keywords, and citation metrics. Additionally, a focused bibliometric exploration involving the search terms (TS = (COVID) OR TS = (COVID-19) OR TS = (corona virus disease 2019) OR TS = (novel coronavirus) OR TS = (SARS-Cov-2)) identified 44 relevant articles examining the intersections between diabetes, microcirculation, and COVID-19. Arrows within the flowchart indicate the sequential progression of the research process. WoSCC: Web of Science Core Collection; COVID: Coronavirus disease; SARS-Cov-2: Severe acute respiratory syndrome coronavirus 2.

Statistical analysis

We established criteria to filter studies pertinent to our analysis. Initial data extraction was followed by data transformation using CiteSpace (version Advanced 6.3.R1) for format standardization to “.tsv” files. We utilized PubMed primarily for literature information extraction. Given the absence of citation data on PubMed, we preferred to retain 6297 publications from WoSCC after eliminating duplicates with PubMed using Microsoft Excel (version 16.83). We then excluded abstracts, reviews, meta reviews, letters, commentaries, study protocols, editorials, guidelines, and any other nonoriginal data, which led to the removal of 936 and 280 articles from WoSCC and PubMed, respectively, culminating in a dataset of 12886 publications for detailed analysis.

A protocol ensuring consistency and accuracy was adhered to during data extraction and analysis. The titles and abstracts of the retrieved articles were screened by two independent reviewers to determine potential relevance. Discrepancies were resolved through consensus, involving a third reviewer when necessary. Full texts of selected studies were obtained and evaluated against the inclusion and exclusion criteria. Disagreements regarding full-text eligibility were resolved through discussion, including a third reviewer as needed.

Bibliometric analysis and visualization maps

A comprehensive bibliometric analysis was performed to delineate the most influential countries/regions, institutions, authors, journals, and keywords within the research domain of diabetes and microcirculation. We utilized SCImago Graphica (version Beta 1.0.32) for visualizing the geographic distribution of the publications. For detailed bibliometric mappings, including co-authorship, co-occurrence, and citation networks among keywords, authors, countries/regions, organizations, and references, VOSviewer (version 1.6.19) was employed.

To discern research hotspots and emerging trends, we generated keyword burst and timeline visualizations using CiteSpace. Additionally, ECharts (version 5.5, https://echarts.apache.org/) was employed to construct bubble charts, which illustrated the temporal trends of annual publications, thereby providing a dynamic representation of research activity over time in the field.

RESULTS

Temporal dynamics of research output in diabetes and microcirculation

A comprehensive search through the WoSCC and PubMed databases yielded a comprehensive dataset comprising 11357 and 9042 records, respectively (Figure 1). An initial publication, pioneering the intersection of diabetes and microcirculation studies, emerged in 1959. From this juncture until 2010, the corpus of literature expanded at a gradual pace. However, a pronounced escalation in scholarly output was noted after 2010, exemplified by a leap from 394 articles in 2011 to 827 in 2023, as depicted in Figure 2A. This burgeoning trajectory indicates a burgeoning scholarly focus with the interplay between diabetes and microcirculation, possibly propelled by technological strides and heightened cognizance of microcirculatory dynamics in the etiology and sequelae of diabetes.

Figure 2 Temporal and geographic trends in diabetes-microcirculation research. This figure elucidates various aspects of the research landscape in diabetes and microcirculation. A: Panel charts the progression of annual publication volumes, reflecting an escalating interest within the academic community; B: Panel shows a map illustrating the geographical dispersion of research contributions on a global scale; C: Panel displays a co-citation network for different countries/regions, highlighting the collaborative dynamics among international research entities. The bibliometric relationships among these nations are indicated by the line thickness in the network diagrams, where a thicker line suggests stronger linkages. Additionally, the node size in these diagrams corresponds to the mean publication count per year for each country, shedding light on the scholarly influence and dissemination of the research from these areas. The circles are color-coded according to the average annual citation rate, visually encapsulating citation dynamics over time; D-F: Panels explore the annual publications metrics for selected nations, specifically the United States of America (E), Australia (E), Italy (D), the United Kingdom (F), and China (D).

Geographic distribution and collaborative networks in diabetes-microcirculation research

The geographic distribution of the research corpus revealed contributions from 83 nations/regions (Figure 2B and C). The citation landscape was dominated by outputs from North America, Europe, and Asia, amassing 226817, 181631, and 53717 citations respectively. The United States (3359 documents), China (1931 documents), the United Kingdom (1187 documents), Australia (697 documents), and Italy (666 documents) surfaced as the vanguards of research productivity (Figure 2D-F; Supplementary Table 1). An examination of international research consortia uncovered robust collaborative undertakings, particularly between the United States and China (227 collaborations) and between the United States and the United Kingdom (203 collaborations). These patterns reflect the globalized nature of diabetes and microcirculation research, where cross-border partnerships are instrumental in fostering knowledge transfer, pooling expertise, and catalyzing advancements in the comprehension and therapeutic targeting of diabetic pathophysiological processes.

Institutional impact and leadership in diabetes-microcirculation studies

The institutional analysis pinpointed a triad of nations, the United States, the United Kingdom, and Australia, as the epicenters of citation impact, with their institutions accruing 51678, 40156, and 24794 citations, respectively. Among them, the Radcliffe Infirmary, the University of Wisconsin, and Harvard University emerged as the leading contributors, with 12755, 12039, and 15401 citations, respectively (Supplementary Table 2). Mapping the top 1000 institutions within the cooperative network unveiled interinstitutional synergy, particularly between American and Australian entities (Supplementary Figure 1). These findings spotlight the extensive, diversified institutional engagement in diabetes and microcirculation research and underscore the significance of interinstitutional consortia in propelling the research output of the United States and Australia in this scientific domain.

Journal influence and information dissemination in diabetes-microcirculation research

In the survey of the top-tier academic journals within the realm of diabetes and microcirculation studies, our analysis foregrounds the New England Journal of Medicine as the most influential, amassing 48844 citations (Supplementary Table 3). A co-citation network of journals revealed Diabetes Care as a central node, indicative of its substantial sway over the research trajectory in diabetes and microcirculation (Supplementary Figure 2). This journal's prominence within the co-citation network attests to its status as a primary conduit for disseminating ground-breaking findings and shaping the research agenda in this domain.

Authorship patterns and collaborative structures in microcirculatory dysfunction research

Delving into the authorship landscape, our investigation counted 777 contributing authors in the field of diabetes and microcirculation. Tien-Yin Wong emerged as the most prolific author, contributing to 202 publications (Supplementary Figure 3), and demonstrated a robust pattern of collaboration within the authorial community (Supplementary Figure 4). Holman RR commanded the highest co-citation frequency, with an impressive citation count of 17100 (Supplementary Table 4). These patterns reflect a robust, interconnected network of scholars, underscoring the collaborative nature of research in this area.

Core publications and citational influence in diabetes-microcirculation studies

The creation of a co-cited reference network map elucidated the foundational studies shaping the conversation on diabetes and microcirculation (Supplementary Figure 5). A study by the Diabetes Control and Complications Trial Research Group, published in 1993, stood out with 1052 citations, attesting to its seminal role in the discourse (Supplementary Table 5). This landmark research illuminated strategies to mitigate the onset and progression of diabetic retinopathy, nephropathy, and neuropathy among individuals with type 1 diabetes, accentuating the criticality of microcirculatory function in diabetes management. The prominence of this reference within the citation network underscores its enduring influence and the value placed on microcirculatory considerations in diabetes-related complications. The analytical lens cast upon co-cited references furnishes a historical context and underscores the pivotal contributions that continue to inform and direct scientific inquiry in this sphere.

Keyword analysis unveiling the research landscape and emerging trends in diabetes-microcirculation

Our extensive keyword co-occurrence analysis, encapsulated in Figure 3A and B, reveals the prevailing thematic pillars in diabetes and microcirculation research. Among the top 8 identified keyword clusters, "oxidative stress", and "mortality" boasts the largest keyword volumes, with 267 and 190 keywords, respectively (Supplementary Table 6), signifying their substantial influence within the field. "Diabetes mellitus" has emerged as the most cited keyword, appearing 4264 times (Figure 3C; Supplementary Table 7), which highlights its centrality in the ongoing scientific discourse.

Figure 3 Keyword dynamics and thematic clusters in diabetes-microcirculation research. A: Panel shows the clustered grouping of these keywords, indicating thematic concentrations in the research; B: Panel presents a timeline of keyword clusters within the field. Circles are color-coded to represent the year each keyword first appeared in the literature, providing a historical perspective on the evolution of research themes. The size of each node indicates the volume of documents associated with that keyword, highlighting the prevalence of specific topics within the field; C: Panel depicts a co-occurrence network of keywords, where the node size reflects the frequency of keyword citation, underscoring the relative prominence of certain terms. The spatial proximity between nodes indicates their co-occurrence in literature, while the thickness of the connecting lines quantifies the strength of these associations. The color of each circle indicates the average citation year of the documents in which the keywords appear, offering insights into the temporal relevance of different topics.

A visualization of keyword interrelationships is presented in Figure 4. There is a discernible linkage between "microcirculation" and several pivotal terms, including "diabetes mellitus", "type 2 diabetes", and "endothelial dysfunction" (Figure 4A and B), whereas a triadic association is noted among "oxidative stress", "diabetes mellitus", and "microvascular complications" (Figure 4C and D). Notably, "methodology" remains an outlier with no observed connections (Figure 4E), and "polymorphism" exhibits a solitary link to "diabetes mellitus" (Figure 4F). Conversely, "care" is interlinked with "diabetes mellitus", "type 2 diabetes", and "microvascular complications" (Figure 4G). This cluster and keyword co-occurrence landscape offers a window into the focal points and trajectories steering diabetes and microcirculation inquiry (For more detailed analysis of keywords related to COVID-19 and microRNA in the field of diabetes and microcirculation, please see Supplementary material and Supplementary Figures 6 and 7).

Figure 4 Detailed keyword association networks in diabetes-microcirculation studies. This figure elaborates on the relationships between central keywords and their associated terms within the domain of diabetes and microcirculation. A-G: Each panel focuses on a specific keyword ("microcirculation", "endothelial dysfunction", "oxidative stress", "microvascular complications", "methodology", "polymorphism", and "care") and visualizes its connections to other relevant keywords. Node size corresponds to the frequency of usage of each keyword, illustrating the dominance or focus of certain terms in the literature. The distance between nodes depicts the linkage based on keyword co-occurrence, while the thickness of the lines indicates the strength of these connections, providing a metric of association strength between topics.

Citation bursts in diabetes-microcirculation research

The identification of keywords with the most citation bursts, as depicted in Figure 5A and B, serves as a beacon to the dynamic research hotspots within the field. The keyword "IDDM (insulin-dependent diabetes mellitus)" heralded the citation burst chronology, surfacing in 1990 with an exceptional burst strength of 92.84 (Supplementary Table 8). The contemporary landscape, particularly over the last decade, is characterized by keywords such as "diabetic kidney disease", "optical coherence tomography angiography", and "diabetic retinopathy". These findings suggest a research frontier keenly focused on the diagnosis, prognosis, and management of diabetic complications. The evolution of these citation bursts provides a roadmap of the field's intellectual progression, spotlighting seminal work and signaling emergent research frontiers.

Figure 5 Impactful keywords and core research themes over time. A: Panel portrays the 25 most impactful keywords, demonstrated through their citation bursts from 1959 to 2023. The timeline is visualized with blue lines, whereas periods of intensified citation activity are marked in red, pinpointing when certain themes surged in academic relevance. This representation effectively traces the temporal dynamics of topic prominence within the field. Terms such as NIDDM and IDDM are highlighted, underscoring significant focal points of both historical and current research endeavors; B: Panel delineates four principal themes central to diabetes and microcirculation research. The inner circle categorizes the main topics, while the outer ring elaborates on the specific aspects associated with each theme. IDDM: Insulin-dependent diabetes mellitus; NIDDM: Non-insulin-dependent diabetes mellitus.

DISCUSSION

The current bibliometric assessment provides a panoramic view of the corpus of literature on diabetes and microcirculation, leveraging extensive datasets accrued from the PubMed and WoSCC databases. This investigation traces the academic lineage of diabetes back to antiquity, yet it indicates a pivotal inflection point occurring in 1959, with the seminal work of Ditzel and Moinat[13] that first illuminated the interconnection between diabetes and microvascular function. Since this discovery, the volume of research has surged, reflecting intensified scholarly engagement with the communication between these two critical areas of medical science.

The analytical examination of prevalent keywords reveals critical themes, namely "endothelial dysfunction", "nitric oxide", and "nitric oxide synthase", indicating the significance of microcirculatory endothelial dysfunction within the pathophysiological framework of diabetes. The integrity of the microvasculature is essential for tissue health, with its compromise signifying disease progression in both type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). Endothelial cells, as custodians of vascular homeostasis, face systemic repercussions from disruptions due to hypoxia, inflammation, or oxidative stress. Hypoxic conditions stabilize HIF-1α[14], triggering a cascade of events that increase proinflammatory and proangiogenic factors, including VEGF[15], thereby promoting vascular dysregulation and subsequent microvascular complications. Inflammation serves as a pivotal force, with cytokines such as TNF-α[16] and IL-1β[17] driving endothelial dysfunction through the activation of the NF-κB pathway, which correlates with impaired vasodilation, increased permeability, and aberrant angiogenesis[18-20]. Concurrently, oxidative stress, driven by reactive oxygen species and advanced glycation end products, exacerbates endothelial injury by depleting NO availability[21,22] and inducing the expression of vasoconstrictors such as ET-1[23]. These insights align with existing literature while emphasizing the detrimental effects of oxidative stress on microvascular health. Furthermore, our analysis identified emerging biomarkers related to endoplasmic reticulum stress and SGLT-2, implicating them in the pathogenesis of vasoconstriction, inflammation, and thrombosis[24]. Collectively, these findings highlight the complexities of diabetes pathophysiology, urging the medical research community to elucidate these multifaceted processes, which reveal both mechanistic insights and potential therapeutic targets.

Bibliometric insights from the current study emphasize the increasing focus on diabetic complications within the nexus of diabetes and microcirculation research, as indicated by the IDF's alarming statistic of 6.7 million adult deaths due to diabetes or its complications in 2021[25]. Microcirculatory dysfunction serves as a critical link to systemic complications such as cardiovascular disease, peripheral neuropathy, diabetic kidney disease, and retinopathy. This dynamic relationship indicates that microvascular dysfunction not only characterizes diabetes but also precedes significant macrovascular issues, with early endothelial dysfunction correlated to the onset of atherosclerosis and subsequent cardiovascular events[26]. Understanding microvascular health is essential for preventing and managing macrovascular diseases, as this dysfunction creates a vicious cycle of pathophysiological decline that necessitates reliable, noninvasive assessment methods.

Traditional techniques like intravital microscopy can disrupt microcirculation, limiting its clinical applicability. Consequently, non-invasive modalities like laser Doppler flowmetry and optical coherence tomography angiography have emerged as essential tools for comprehensive evaluations of microvascular function[27,28], and management of diabetic microvascular complications[29]. Additionally, technologies such as sidestream dark field imaging, near-infrared spectroscopy, and diffuse reflectance spectroscopy enable real-time monitoring of tissue perfusion and oxygenation[30-32]. To thoroughly evaluate diabetic microcirculation, it is imperative to integrate various detection techniques and adopt multi-organ synergistic analyses, aligning these advancements with clinical practice. Such interdisciplinary integration will enhance our understanding of the pathophysiological mechanisms of diabetic microcirculation and improve our ability to prevent and mitigate its severe complications, steering diabetes care towards more precise, predictive, and personalized interventions.

The heterogeneity in microcirculatory dysfunction between T1DM and T2DM reveals essential distinctions in their pathophysiological mechanisms, presenting opportunities for targeted therapeutic interventions. In T1DM, endothelial dysfunction arises primarily through oxidative stress and inflammatory cytokine release, leading to microvascular complications. In contrast, T2DM involves insulin resistance, β-cell dysfunction, and comorbidities such as obesity and dyslipidemia, which exacerbate microvascular impairment via systemic inflammation and disrupted lipid metabolism. Our bibliometric analysis reveals a significant trajectory of research emphasizing the clinical potential of microcirculation-focused interventions in diabetes management. While insulin remains foundational for facilitating glucose uptake and reducing hepatic glucose output[33], advancements in pharmacotherapy, such as metformin, alogliptin, and liraglutide, have further enhanced strategies to combat microvascular dysfunction characteristic of diabetes[34-36]. Cellular therapy, particularly through stem cell transplantation, presents a promising avenue by targeting microvascular endothelial cells and restoring islet cell functionality via the differentiation of pluripotent cells.

Technological innovations have transformed healthcare, improved life expectancy and fostered holistic disease management. The critical role of microcirculation in diabetes is increasingly apparent, with early-stage diabetes linked to endothelial impairment that disrupts microcirculation and essential physiological functions. Heightened retinal microvascular permeability has been correlated with incipient diabetic retinopathy prior to clinical diagnosis, underscoring the potential of microcirculation as an early sentinel for detection and intervention[37,38]. As diabetes progresses, alterations in microhemodynamics and tissue oxygen complicate the clinical landscape, offering insights into potential complications and refining management strategies. Furthermore, incorporating perspectives from bioengineering and pharmacology enriches our understanding of microcirculatory dysfunction. Continuous glucose monitoring systems, augmented by machine learning algorithms and wearable monitors, has revolutionized diabetes care by addressing challenges related to cost and long-term safety[39,40]. Nanoscale biomaterials (polyelectrolyte nanoparticles for example) targeted drug delivery and microfluidic platforms that simulate microvascular environments enable precise modeling of endothelial interactions. Concurrently, pharmacological innovations like GLP-1 receptor agonists and SGLT2 inhibitors not only improve glycemic control but also provide protective effects on microvascular health, with tailored delivery systems further optimizing their bioavailability within microvascular tissues, thereby enhancing therapeutic outcomes. By prioritizing microcirculation in diabetes management, comprehensive strategies can be developed to mitigate mortality, morbidity, and the progression of microvascular complications, establishing it as a critical marker for diabetic sequelae. Moving forward, it is imperative for the scientific community to persist in innovation, enhancing our understanding and interventions that hinge on the intricate dynamics of microcirculation. Through sustained inquiry and technological advancements, we can overcome existing limitations and unlock the full potential of diabetes management, alleviating the substantial burden this disease imposes on individuals and healthcare systems globally.

The concentration of diabetes research in North America, Europe, and regions of Asia raises significant concerns regarding global health equity and the generalizability of findings. Disparities in funding, research infrastructure, and technological access, along with cultural and socioeconomic influences, contribute to this imbalance, limiting our understanding of microcirculatory dysfunction in underrepresented populations and exacerbating existing health disparities. To address these inequalities, it is essential to promote transnational and regional cooperation through the establishment of global research networks that facilitate collaborative efforts. Such initiatives are poised to accelerate scientific discovery and enhance the global management of diabetes. However, reliance on established databases such as WoSCC and PubMed, while bolstering the robustness of our analysis, presents inherent limitations. The exclusion of relevant studies not indexed in these databases may compromise data comprehensiveness. Additionally, the focus on English-language literature introduces a potential bias, potentially overlooking contributions from non-English publications. Despite these constraints, the findings and trends identified are expected to retain broad applicability to understanding diabetes and microcirculation on a global scale.

CONCLUSION

In conclusion, our bibliometric analysis, encompassing six decades of research, reveals the dynamic intersection of diabetes and microcirculation that enriching our understanding of microvascular endothelial dysfunction and its pivotal role in the pathophysiology of diabetes. To propel the field forward, we advocate for a comprehensive research strategy that integrates microcirculatory factors. Future research should prioritize identifying gaps in the existing literature, particularly the standardization of microcirculation assessment protocols and the evaluation of innovative therapeutic approaches. Moreover, the integration of advanced microcirculation assessment techniques into clinical practice is essential for formulating effective therapeutic strategies. By addressing both microvascular and macrovascular risks, it is imperative to develop effective strategies that facilitate the translation of these advanced methodologies and interventions into routine healthcare settings, thereby bridging the divide between microcirculation research and diabetes management and ultimately enhancing health outcomes on a global scale.