Diabetes Core Update – November 10, 2013

Overview

In this episode of Diabetes Core Update, Drs. Neil Skolnik and John J. Russell examine five recently published articles from the American Diabetes Association’s scientific and medical journals. The discussion centers on new findings in metabolic risk with breakfast frequency, weight loss interventions in prediabetes, non-cardiac surgery outcomes in diabetics, updated aspirin therapy recommendations, and the metabolic effects of fructose and uric acid. The focus throughout is on clinical implications for healthcare professionals treating patients with or at risk for diabetes.

Key Discussion Points & Insights

1. Breakfast Frequency and Metabolic Risk (00:55–03:13)

• Study: CARDIA (Coronary Artery Risk Development in Young Adults) investigation, published in Diabetes Care.
• Population: ~3,600 adults without diabetes at baseline, tracked for 18 years.
• Findings:
  • Those eating breakfast 4–6 or 7 days a week gained 1.9 kg (approx. 4 lbs) less than those who rarely ate breakfast.
  • Stepwise decrease in risk for abdominal obesity, metabolic syndrome, hypertension, and type 2 diabetes among daily breakfast eaters.
  • Adjusted hazard ratios demonstrated significant risk reduction even when accounting for baseline weight.
• Clinical Perspective: “5 pounds less weight gain over 18 years, improved metabolic parameters, all just from eating a good breakfast… there might be something going on here that really supports what our mothers always told us.” — Dr. Skolnik (03:13)
  • Emphasis on growing evidence supporting breakfast for metabolic health.
  • Reference to other controlled studies showing similar results for caloric intake distribution.

2. Liraglutide in Prediabetes and Weight Loss (03:13–06:15)

• Study: Randomized controlled trial of liraglutide 1.8mg vs. placebo over 14 weeks; participants: overweight/obese adults with prediabetes (mean age 58).
• Results:
  • 31% liraglutide group dropout vs. 18% in placebo.
  • Those who completed liraglutide lost twice as much weight as placebo (6.8 kg vs. 3.3 kg).
  • Improved fasting glucose, systolic blood pressure, and triglycerides in liraglutide group.
• Clinical Perspective: “It just seems… having our patients do an injectable medicine, you know, over a 14 week period of time… we don't know if the people kept this weight off kind of long-term… The question is, is it a practical approach for these patients?” — Dr. Russell (06:15)
  • Skepticism about the practicality and long-term benefit of injectable therapy for this common population.
  • Question raised about whether lifestyle interventions could have similar outcomes.

3. Non-Cardiac Surgery Outcomes in Diabetes (06:15–08:59)

• Study: Taiwanese nationwide retrospective cohort (insurance claims), comparing non-cardiac surgical outcomes in patients with and without diabetes.
• Findings:
  • Diabetic patients had increased 30-day mortality (OR 1.84).
  • Risks amplified for those with type 1 diabetes, uncontrolled diabetes, or preoperative complications.
  • Co-morbidities like renal dialysis, cirrhosis, stroke, ischemic heart disease further increased risk.
  • Higher rates of postoperative renal failure and MI, longer hospital stays, higher medical costs.
• Clinical Perspective:
  • Dr. Skolnik points out selection bias: “They just included patients with diabetes who had been admitted to the hospital at some point during the prior 24 months… it wouldn't be entirely surprising that they don't do as well as an age matched population without diabetes who've been well previously.”
  • Key practical advice: optimize glucose and comorbidities prior to surgery, vigilant perioperative management (esp. glucose 140–180 mg/dL, EKG monitoring).

4. Aspirin Therapy in Diabetes: Current Recommendations (08:59–14:31)

• Overview: Review of aspirin’s evidence base for primary cardiovascular disease prevention in diabetes. (Diabetes Spectrum)
• Evidence:
  • Physicians’ Health Study: 44% MI reduction with aspirin every other day in healthy men.
  • Risks: 40% increase in serious GI bleeding in aspirin users.
  • ADA recommends aspirin for primary prevention in diabetics with >10% 10-year CVD risk (generally men >50, women >60).
  • Not recommended for men under 50 and women under 60 at low risk (<5%), as bleeding risk outweighs benefits.
• Memorable Moment:
  • “Aspirin use dates back to the time of the Sumerians. Aspirin was really a product of the Bayer company...” — Dr. Russell (13:24)
  • Concise clinical pearl: “Aspirin is effective in higher risk folks and it's really more dangerous than effective in low risk folks... a large cohort of folks with diabetes who are older…are going to get by just as well with a baby aspirin as a full aspirin.” — Dr. Russell (14:19)

5. Fructose, Uric Acid, and the Rise of Obesity (14:31–16:36)

• Review Article (Diabetes): Mechanisms relating high fructose intake to metabolic syndrome, obesity, and diabetes.
• Key Points:
  • Animals fed fructose develop more metabolic syndrome features than those fed glucose.
  • Fructose suppresses insulin/leptin —> reduced satiety, higher caloric intake.
  • Human studies: Fructose reduces resting energy expenditure.
  • Fructose increases uric acid —> hepatic lipogenesis, risk for NAFLD (non-alcoholic fatty liver disease).
  • High fructose corn syrup has paralleled the US obesity epidemic since the 1970s.
• Quote:
  • “High fructose corn syrup can lead to an increase in intracellular uric acid that can be followed by a rise in uric acid levels in the circulation ... this may be one of the important reasons or causes for the increase in obesity over the last 30 years.” — Dr. Skolnik (15:50)
• Caveats:
  • Dr. Russell adds: Only ~34 of the 458 extra daily calories (since the 1970s) are from high fructose corn syrup. “I think calories are calories and we really need to be concentrating on these 500 extra calories we’ve picked up per day over the last 40 years.” — Dr. Russell (17:30)
  • Noted that even countries using sugar instead of high-fructose corn syrup (e.g., Mexico) have high obesity rates.

Notable Quotes & Memorable Moments

• On breakfast and health: "Eat breakfast like a king, lunch like a prince, and dinner like a pauper... over the years have supported the eating of a good breakfast in the health profession." — Dr. Skolnik (03:00)
• On liraglutide practicality: “The question is doing an injectable medicine, is it just a practical approach for these patients?” — Dr. Russell (06:15)
• On perioperative management: “We want to be careful about the word ‘cleared’... what we're really saying is that the benefits of the surgery outweigh the risk and that patients are optimized...” — Dr. Skolnik (09:28)
• Aspirin’s legacy and clinical value: “Aspirin is effective in higher risk folks and it's really more dangerous than effective in low risk folks...” — Dr. Russell (14:19)
• On excess calories: “Calories are calories and we really need to be concentrating on these 500 extra calories we've picked up per day over the last 40 years.” — Dr. Russell (17:30)

Timestamps for Key Segments

• 00:55 — Article line-up and introduction
• 01:42 — Breakfast frequency and metabolic risk
• 03:13 — Liraglutide in prediabetes
• 06:15 — Non-cardiac surgery complications in diabetics
• 08:59 — Aspirin therapy in diabetes
• 14:31 — Fructose, uric acid, and obesity/diabetes etiology
• 16:36 — Broader nutrition and obesity commentary

Takeaways for Clinical Practice

• Regular breakfast consumption appears beneficial for long-term metabolic health and may reduce weight gain and risk of associated metabolic diseases.
• Liraglutide is effective for short-term weight loss and metabolic improvement in overweight/obese prediabetics, but the practicality and cost-effectiveness for broad clinical use remain to be determined.
• Diabetics face significantly higher risks in non-cardiac surgery, particularly with comorbidities. Preoperative planning and glycemic control are paramount.
• Aspirin should be reserved for primary prevention in diabetic patients with substantial cardiovascular risk, not as a blanket therapy.
• High fructose intake plays a role in the obesity epidemic but is just one piece of the puzzle; overall caloric excess remains a primary concern.

For full articles and more, visit: www.diabetesjournals.org