Editorial
In 1892 William Osler wrote “It is more important to know
what kind of a patient the disease has, than to know what
kind of a disease the patient has.” Although health-care
practices have traditionally followed a one-size-fits-all
method, precision medicine aims for a more tailored
approach. However, despite much hype on the potential
of precision medicine, until now there has been little
consensus on its exact definition and clinical relevance.
More data does not necessarily mean improved decision
making and whether precision medicine can be used for
multifactorial conditions, such as obesity and diabetes, is
still a matter of debate.
The Lancet Diabetes & Endocrinology has just published
a four-paper Series on the current status of precision
medicine in cardiometabolic health. The Series aims to
standardise terms and concepts, propose new models
for disease classification, and discuss future directions
including implementation and feasibility of precision
medicine approaches in low-income and middle-income
countries (LMICs). Coinciding with publication of the
Series was the second international consensus report
from the Precision Medicine in Diabetes Initiative, which
discusses precision medicine in diabetes and outlines key
targets for its clinical implementation.
The first paper of The Lancet Diabetes & Endocrinology
Series proposes a novel translational framework that aims
to help the process of translating precision medicine into
clinically meaningful decisions. There is still confusion over
what precision medicine entails. Often, genomic research
is seen as the predominant, if not only, component,
which can lead to the assumption that precision medicine
solely involves costly techniques and technologies that
are not yet widely available. However, precision medicine
can incorporate genetic, environmental, and clinical
markers to improve accuracy at every stage of medical
management—prevention, diagnosis, prediction, treat­
ment, monitoring, and prognosis.
To avoid exacerbating current health-provision
disparities, there must be a concerted effort to ensure that
people from all backgrounds and all nations are included
in each aspect of precision health care. The second paper
of our Series discusses the challenges and implications of
adopting precision medicine in LMICs. Establishing large
reliable databases is key, but despite a large proportion
of people with diabetes residing in LMICs, most of
the current research is performed in cohorts of mainly
European ancestry. Promisingly, there have been positive
steps forward, with projects such as GenomeIndia which
aims to perform whole genome sequencing, increas­ing
opportunities for precision medicine. However, imple­
mentation requires more than data. There will need
to be a shift in health-care policy and public health to
ensure that the public, stakeholders, and politicians are
aware of precision medicine and how it can be utilised to
combat conditions like diabetes. Furthermore, practical
measures such as ensuring there are enough health-care
workers skilled in precision health care and a suitable
IT infrastructure that can process high-volume data
need to be considered and planned for.
Current diagnosis and management methods of
diabetes and obesity do not reflect the complex and
multifaceted nature of these conditions. Globally,
diabetes is diagnosed through measurement of a single
parameter—glucose. Likewise, overweight and obesity
are classified according to BMI, irrespective of differences
in body composition, ethnic background, gender, or
lifestyle. The third paper of the Series proposes a model for
diabetes classification that incorporates the interactions
of different underlying causational processes, such as
obesity and insulin resistance. Similarly, there is also
much interest in devising obesity subtypes that reflect
the different genetic, lifestyle, and environmental
exposures of individuals, and can help clinicians with the
management and treatment of the condition. The final
paper in the Series discusses obesity heterogeneity and
proposes an obesity-centred multi-disease management
plan that targets both obesity and its comorbidities,
especially diabetes.
An overarching theme in the Series is the emphasis on
greater collaboration and accord between governments,
policy makers, and scientists, from both high-income
countries and LMICs, on what the future of precision
medicine should be in practical terms. Often described
as the next evolution of contemporary medicine, there
is great opportunity to focus on the person and not the
disease. However, it is important that in these endeavours,
traditional public health and population-level campaigns
that have shown effectiveness in reducing and managing
conditions such as obesity are not deprioritised.
■ The Lancet Diabetes & Endocrinology
www.thelancet.com/diabetes-endocrinology Published online October 11, 2023 https://doi.org/10.1016/S2213-8587(23)00293-0
Sam Falconer, Debut Art/Science Photo Library
Precision medicine: improving accuracy, reducing error
Lancet Diabetes Endocrinol 2023
Published Online
October 11, 2023
https://doi.org/10.1016/
S2213-8587(23)00293-0
For more on William Osler see
JAMA 1936; 106: 566
For the Series on Precision
medicine see https://www.
thelancet.com/series/precisionmedicine
For more on the Second
international consensus report
on gaps and opportunities for
the clinical translation of
precision diabetes medicine see
https://www.nature.com/
articles/s41591-023-025025#:~:text=This%20second%20
international%20consensus%20
report,type%201%2C%20
type%202)
For more on the framework for
precision medicine see Series
page 822
For more on precision medicine
in LMICs see Series page 836
For more on GenomeIndia see
https://dbtindia.gov.in/
scientific-decision-units/
computational-biology/
genome-india-and-microbiome
For more on diabetes
heterogeneity see Series
page 848
For more on precision medicine
of obesity as an integral part of
diabetes management see
Series page 861
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