Diabetes Core Update – June 10, 2013

Episode Overview

This episode of the Diabetes Core Update podcast, hosted by Dr. Neil Skolnik and Dr. John Russell, delivers concise, clinically relevant summaries of six pivotal new research articles from the American Diabetes Association’s four scientific journals. Geared toward practicing physicians and healthcare professionals, the discussion centers on the real-world implications for diabetes care stemming from studies on bariatric surgery, fracture risk, medications, intensive lifestyle interventions, and vitamin D’s role in diabetes development.

Key Discussion Points & Insights

1. Bariatric Surgery: Reconsidering Eligibility Criteria

(00:55 – 03:28)

• Article Summary: Explores outcomes from the Swedish Obese Subjects (SOS) study, specifically whether traditional NIH BMI criteria (≥40 or ≥35 with comorbidities) remain the most appropriate determinant for bariatric surgery eligibility.

• Findings: Both NIH-eligible and non-eligible bariatric surgery patients saw significant cardiovascular risk factor improvement. Most notably, surgery reduced diabetes incidence by ~70% in both groups after 10 years, with no difference between them.

• Clinical Take: Data supports reconsidering restrictive surgical criteria, as those currently deemed “ineligible” benefit similarly. The conversation highlights broader societal and economic impacts of reducing diabetes incidence through surgery.

  Memorable Quote:

  “If you prevent all these people from developing diabetes, how much dialysis down the road are you going to prevent? How much blindness, how much heart disease, how many premature deaths are you going to prevent?”
  — Dr. John Russell [03:13]

2. Diabetes and Fracture Risk

(03:28 – 06:14)

• Study: ARIC (Atherosclerosis Risk in Communities) study examining diabetes, glycemic control, and fracture-related hospitalization over 20 years in 15,000 participants.

• Findings:

  • Diagnosed diabetes independently increases fracture risk (hazard ratio, HR = 1.74).
  • Insulin-treated patients (HR = 1.87) and those with A1C >8% (HR = 1.63) have even higher risk.

• Guideline Implications: The popular FRAX fracture prediction tool does not include diabetes as a risk factor, suggesting a gap in current screening protocols.

  Memorable Quote:

  “Patients with diabetes may have approximately a 70–80% increased risk of fracture… We might think about screening those patients for osteoporosis at an age that is younger than that which they would otherwise be screened.”
  — Dr. Neil Skolnik [06:05]

3. Once-Weekly Exenatide vs. Insulin Detemir

(06:14 – 09:27)

• Study: Randomized trial (216 patients) comparing once-weekly exenatide (GLP-1 receptor agonist) to once/twice-daily insulin detemir for 26 weeks.

• Results:

  • 44% of exenatide users achieved A1C ≤7% with ≥1kg weight loss, compared to just 11% on detemir.
  • Greater A1C reduction (-1.3% vs -0.88%) and weight loss (-2.7kg vs +0.8kg) with exenatide.
  • More GI and injection site side effects, and higher dropout rates for exenatide.

• Practice Implication: Once-weekly GLP-1 agonists represent a promising, less burdensome alternative for many, but side effects limit use.

  Memorable Quote:

  “Someone giving themselves an injection once a week… did just as well blood sugar wise and in fact had some weight loss associated with it. Very exciting.”
  — Dr. John Russell [09:32]

4. Look AHEAD Trial: Intensive Lifestyle Modification

(09:27 – 12:09)

• Study: Four-year follow-up of nearly 4,000 overweight/obese adults with type 2 diabetes, randomized to intensive lifestyle intervention (ILI) vs. standard support and education.

• Findings:

  • ILI resulted in significantly higher physical activity (+348 vs +105 kcal/week) and improved fitness levels.
  • Fitness improvement inversely tied to A1C change, even after adjusting for baseline characteristics and weight.
  • Despite not achieving reduced cardiovascular event rates (primary endpoint), ILI meaningfully improved secondary outcomes such as fitness, weight, and glycemic control.

  Memorable Quote:

  “If we can help our patients feel better with fitness and improve their A1Cs without additional use of medicines, then clearly we've made some important effects for them.”
  — Dr. Neil Skolnik [13:03]

5. Vitamin D and Development of Diabetes

(12:09 – 15:26)

• First Article: Large cohort (100,000+ participants from 4 million patient data set) finds lower vitamin D levels associated with higher risk of developing diabetes or progressing from impaired fasting glucose.

• Meta-Analysis: 21 studies (75,000+ people) confirm those with highest vitamin D have a 38% lower diabetes risk compared to lowest levels (RR = 0.62).

• Interpretation: Low vitamin D is consistently associated with diabetes risk, but causality is not established; supplementation benefits remain unproven.

  Memorable Quote:

  “It certainly might be a surrogate marker that these are some folks who have some overall kind of poor health… causality, I still think is a leap of faith.”
  — Dr. John Russell [15:19]

Notable Quotes & Highlights

| Timestamp | Speaker | Quote | |-----------|----------------------|-------------------------------------------------------------------------------| | 03:13 | Dr. John Russell | “If you prevent all these people from developing diabetes, how much dialysis...| | 06:05 | Dr. Neil Skolnik | “Patients with diabetes may have approximately a 70–80% increased risk of... | | 09:32 | Dr. John Russell | “Someone giving themselves an injection once a week… did just as well... | | 13:03 | Dr. Neil Skolnik | “If we can help our patients feel better with fitness and improve their A1Cs...”| | 15:19 | Dr. John Russell | “It certainly might be a surrogate marker that these are some folks... |

Timestamps for Important Segments

• 00:55 – Bariatric surgery eligibility and SOS study summary
• 03:28 – Diabetes and fracture risk, ARIC study
• 06:14 – Once-weekly exenatide vs. insulin detemir trial
• 09:27 – Look AHEAD: intensive lifestyle intervention
• 12:09 – Vitamin D levels and diabetes risk

Conclusion

This episode of Diabetes Core Update underscores the evolving landscape of diabetes management and risk prediction:

• Bariatric surgery offers profound benefits even for patients outside current eligibility guidelines, challenging the status quo.
• Diabetes’ association with fracture risk suggests the need for reconsidered osteoporosis screening strategies.
• GLP-1 agonists like exenatide provide convenient, effective alternatives to insulin with added weight-loss benefits.
• Lifestyle interventions improve fitness and glycemic control, even if cardiovascular event reductions are elusive.
• Vitamin D’s link to diabetes is robust in observational data, but interventional evidence is pending.

For further reading, visit www.diabetesjournals.org.