Diabetes Core Update (1/10/2013) – Episode Summary

Overview

This episode of Diabetes Core Update (January 10, 2013), hosted by Dr. Neil Skolnik and Dr. John Russell, presents and discusses recent clinically relevant articles from ADA journals. Special guest Dr. William Cefalu, Editor of Diabetes Care, provides insights on two key articles. The episode covers behavioral interventions for promoting physical activity in type 2 diabetes, upcoming changes in A1C reporting, projections of childhood diabetes, treatment options for diabetic neuropathy, the DASH diet for diabetes, and the effect of exercise on breast cancer risk in women with diabetes. The tone is practical and focused on real-world application for clinicians.

Key Discussion Points and Insights

1. Behavioral Interventions to Improve Physical Activity in Type 2 Diabetes

[02:03–06:28]

• Reviewed a systematic review and meta-analysis of 17 RCTs on behavioral interventions.
• Findings:
  • Behavioral strategies led to significant increases in both objective and self-reported physical activity.
  • Clinical improvements: A1C decreased by approximately 0.3%, and BMI decreased by about 1 point.
  • Interventions were most effective when underpinned by behavior change theories and employing over 10 behavior change techniques.
• Effective Components:
  • Set clear, specific behavioral goals.
  • Conduct regular follow-up, either via phone or in-office.
  • Enlist social support structures for patients.
  • Provide anticipatory guidance, leveraging patient's previous successes and challenges.
• Quote:

  "Efforts to help people change their behavior work when it's carried out in a systematic multimodal fashion... People doubled their exercise amount roughly, they dropped their A1Cs by about 0.3%, and they decreased their BMIs by 1 compared to the group that just got usual care."
  — Dr. Neil Skolnik [03:03]

2. Changes in Hemoglobin A1C Reporting: Dual Units

Guest: Dr. William Cefalu, Editor, Diabetes Care
[06:28–11:26]

• Historical context: A1C reporting in % is rooted in landmark research (DCCT, UKPDS), but there's a global movement toward standardizing A1C reporting in SI units (mmol/mol).
• Growing confusion due to different countries and journals using different units.
• Recommendation: Publish A1C results in both % and SI (mmol/mol) for greater clarity and international comparability.
• Key Challenge: Simple conversion between units is not possible; calculation via a specific equation is required.
• Implications: Need for education at both clinician and patient levels as the reporting transitions.
• Quote:

  "It's not as easy to convert percent or international units. You actually have to use an equation... This is going to be great education for physicians, for researchers, and it's going to be even more education for patients."
  — Dr. William Cefalu [09:24]

3. Alarming Projections of Diabetes in U.S. Youth by 2050

Guest: Dr. William Cefalu
[11:26–17:19]

• Study used census data to project future diabetes rates in individuals under 20.
• Findings:
  • 23% increase in type 1 diabetes incidence among youth by 2050.
  • 49% increase in type 2 diabetes incidence in the same group.
• Clinical Significance:
  • Raises concern about morbidity and mortality, given earlier disease onset.
  • Ethnic shifts in type 1 diabetes prevalence anticipated.
• Prevention imperative: Lifestyle modification in youth is more challenging than in adults due to developmental and social factors.
• Quote:

  "It's scary...this particular study actually estimates that for type 1 diabetes, a 23% increase...and almost a 49% increase in type 2 diabetes in this particular age range over the next 40 years."
  — Dr. William Cefalu [12:24]

4. Comparative Efficacy of Medications for Diabetic Peripheral Neuropathic Pain

[17:19–18:31]

• Double-blind RCT comparing amitriptyline, duloxetine, and pregabalin.
• All three medications reduced pain by about 50% versus placebo.
• Side effects:
  • Pregabalin: better sleep continuity, but more daytime drowsiness.
  • Duloxetine: increased wakefulness and attentiveness but reduced total sleep time.
  • Amitriptyline: caution in elderly due to side effects (e.g., orthostatic hypotension).
• Clinical takeaway: All three are viable; individualize based on side effect profiles and patient characteristics.
• Quote:

  "Amitriptyline is an old drug, a good drug, but often not the best drug to give especially in our elderly patients..."
  — Dr. John Russell [18:31]

5. DASH Diet for Diabetes Management

[18:31–21:29]

• Review explored research on the DASH (Dietary Approaches to Stop Hypertension) plan's benefits for diabetes.
• Key Trials:
  • Premier trial: DASH improved insulin sensitivity, blood pressure, lipids.
  • ENCORE trial: DASH alone reduced blood pressure but needed to be combined with lifestyle intervention for metabolic benefit.
• Clinical Implications: DASH is effective for blood pressure and possibly for diabetes. Success relies more on diet adherence and calorie reduction than on diet type.
• Quote:

  "The thing that was the best predictor of weight loss in patients wasn't the type of diet that they were on, but their degree of motivation in adhering to the diet so that it really is about calories."
  — Dr. Neil Skolnik [21:29]

6. Exercise and Breast Cancer Risk in Diabetic Women

[21:29–24:50]

• Population-based case–control study on moderate physical activity's effect on breast cancer risk among women with diabetes.
• Findings:
  • Higher levels of moderate activity linked to lower breast cancer risk (odds ratio dropped from 4.93 to 1 across tertiles of activity).
  • Serum markers (C peptide, IGF1, IGFBP3) used for mechanistic analysis.
• Commentary: Exercise appears protective; methodology could be more robust.
• Quote:

  "Obesity has been linked with breast cancer, obesity has been linked with colon cancer, and it would certainly follow that people who exercise perhaps can decrease some of that risk."
  — Dr. John Russell [23:55]

Notable Quotes & Memorable Moments

• On behavioral change:
  "No one can do it alone. Figuring out who your patient's main supports are and getting them to help carry out the encouragement for those behavioral changes, because behavioral changes aren't easy to begin with and they're even harder to sustain." — Dr. Neil Skolnik [03:39]

• On challenges of diabetes prevention in youth:
  "For kids, it's got to be done in a way that they enjoy because unlike adults, they don't set their goals necessarily and go after it. They do what feels right and perhaps video games feel too right and sports and eating well doesn't feel right enough." — Dr. Neil Skolnik [15:36]

Timestamps by Segment

• [02:03] Behavioral strategies for physical activity in type 2 diabetes
• [06:28] Dr. Cefalu on A1C reporting and measurement changes
• [11:26] Projections for youth diabetes through 2050
• [17:19] Diabetic neuropathy—pharmacologic treatment comparison
• [18:31] DASH diet review for diabetes management
• [21:29] Exercise and risk reduction for breast cancer in diabetic women

Conclusion

This episode delivers practical, evidence-based updates for clinicians on behavioral and pharmacologic interventions, dietary recommendations, changes in diabetes monitoring and reporting, and epidemiological projections with major implications for future practice and prevention efforts. The discussion remains patient-focused, emphasizing both evidence and achievable, individualized care.