Diabetes Core Update (8/10/2012) – Episode Summary

Podcast: Diabetes Core Update
Date: August 10, 2012
Hosts: Dr. Neil Skolnik & Dr. John Russell
Audience: Practicing physicians and healthcare professionals
Episode Duration: ~15 minutes

Episode Overview

This episode highlights and discusses five recent, clinically relevant articles from ADA's leading journals. Topics range from surgical interventions for type 2 diabetes to pharmacological advances, devices for insulin administration, strategies to preserve beta cell function, and scientific insights on non-nutritive sweeteners. Drs. Skolnik and Russell focus on practical applications and implications for treatment and management of diabetes.

Key Discussion Points & Insights

1. Bariatric Surgery in Mildly Obese Patients with Type 2 Diabetes

Source: Diabetes Care, July 2012
Segment: [00:56 – 04:31]

• Study Focus: Effects of gastric bypass (Roux-en-Y) in type 2 diabetes patients with BMI 30–34.9 (not the traditionally recommended BMI ≥35).
• Participants: 66 patients, mean diabetes duration 12+ years, mean baseline A1C 9.7.
• Findings:
  • Remission (A1C <6.5, no meds) achieved in 88% at 5 years.
  • Improved control (A1C <7 with less medication or no insulin) in another 11%.
  • Resolution of comorbidities: Hypertension (58%), hypercholesterolemia (64%), hypertriglyceridemia (58%).
  • Significant A1C reduction: From 9.7 to 5.9, most change in first 6 months.
  • Safety: No major complications, safer profile than historical norms.
• Clinical Reflection:
  • Dr. Russell [04:31]:

    “The authors were very cautious to not use a term cure, but to use the term remission. But if you're five years out from your surgery and you really have not gone back to needing diabetic medicines, you probably could talk about this as a cure.”

  • Implications:
    • Widespread adoption would have major cost implications.
    • Only Roux-en-Y was studied, not less invasive procedures.
    • The marked reduction in A1C and improvement in comorbidities is "magnificent," particularly in long-standing diabetes.
    • Surgery safer now (mortality 1–2/2000), especially in mildly obese.
  • Open question: Will BMI thresholds keep lowering as research evolves?

2. Exenatide Once-Weekly for Type 2 Diabetes

Source: Clinical Diabetes, Summer 2012
Segment: [04:31 – 11:17]

• Topic: Once-weekly GLP-1 receptor agonist exenatide (first approved once-weekly glucose-lowering agent).

• Comparison: Exenatide weekly vs. other GLP-1 agonists and oral agents.

• Efficacy Data:

  • A1C reduction: –1.3 to –1.9 over 6 months (baseline A1C 8.3–8.5).
  • Sustained effect: –1.6 A1C, –2.3 kg weight loss after 3 years.
  • Comparison: Better A1C reduction than sitagliptin, pioglitazone, exenatide BID, insulin glargine; less than liraglutide.
  • Additional benefits: BP lowering (–6.2 mmHg), improved lipids, low hypoglycemia risk.

• Tolerability:

  • Most adverse events were mild, transient GI effects (nausea 14–26%; less than exenatide BID).
  • Injection site reactions more common than BID.

• Contraindications: Severe renal impairment, history of pancreatitis, medullary thyroid carcinoma/MEN2.

• Prescribing notes: Up to four-day forgiveness if a weekly dose is missed.

• Dr. Skolnik [11:17]:

  “This really fits in as a second line agent very nicely… efficacy, ease of use, a low risk of hypoglycemia... Weight loss is clearly advantageous.” “It was interesting also to see its effect on LDL cholesterol, decreasing LDL cholesterol by about 7%. It doesn't kick in immediately... it takes six to seven weeks to achieve a steady state.”

3. Insulin Pens vs. Vials & Syringes: Patient Benefits and Barriers

Source: Diabetes Spectrum, Summer 2012
Segment: [11:17 – 16:33]

• Theme: Insulin pens simplify administration and improve adherence, but US adoption remains low (<10%).

• Benefits:

  • Ease of use: Especially for older adults (>65) and children/adolescents; increased dosing accuracy and user confidence.
  • Barriers: Failure to start insulin often due to fear or complexity of syringes.
  • Real-world evidence: Lower error rates; easier to teach in office settings.

• Cost: Pens ~25% more expensive than traditional methods, but may be offset by improved adherence (potential net savings on hospitalizations).

• Caveat: Need to prescribe needles separately; not all patients will universally benefit.

• Dr. Russell [16:33]:

  "I think this is one of those issues that can be summed up with it being pennywise and pound foolish. We found a device that works better... if people won't take their insulin, they're more likely to have more morbidity down the line."

• Memorable Tip:

  "If we can figure out a way that you and I can teach someone simply in our office to start insulin... it's a nice way to get people started in a very simple way." – Dr. Russell

4. Long-Term Beta Cell Preservation After Intensive Diabetes Therapy

Source: Diabetes Care, June 2012
Segment: [16:33 – 19:33]

• Study Design: 58 newly diagnosed, treatment-naive type 2 diabetics, all started on insulin+metformin, then randomized:

  • Arm 1: Continue insulin+metformin
  • Arm 2: Triple oral therapy (metformin, glyburide, pioglitazone)

• Outcomes:

  • Beta cell function: Preserved at 3.5 years in both arms (no significant difference).
  • Glycemic control: A1C ~6.35–6.59 for both arms at end of study (excellent).
  • Weight gain: Similar in both arms over time.
  • Hypoglycemia: Decreased over time, similar rates.

• Clinical Insights:

  • Early intensive control may help maintain beta cell function.
  • Don’t use ACCORD trial data to justify lax control in newly diagnosed patients; ACCORD involved patients with established diabetes.
  • Key take-away: Beware of "therapeutic inertia"—delay in escalating therapy when A1C above goal.

• Dr. Skolnik [19:33]:

  "We need to be very careful about therapeutic inertia... This issue of beta cell preservation is going to be very interesting to follow and see as more data comes out how aggressive we really should be in patients new to therapy."

5. Non-Nutritive Sweeteners: Scientific Perspective

Source: Diabetes Care (AHA/ADA Scientific Statement), Online July 2012
Segment: [19:33 – 26:10]

• Background: Around 15% of Americans use non-nutritive sweeteners for weight loss.

  • Statement covered efficacy (not safety; products FDA-approved).

• Key Evidence:

  • For sweeteners to aid in weight loss, users must not compensate with extra calories elsewhere—often not the case.
  • Many studies reveal only a 15–30% true calorie reduction; the rest is offset by "compensatory eating."
  • Weight outcomes inconclusive: Some studies show weight loss, others little effect.
  • No significant glycemic impact in 4 RCTs (1–16 weeks).

• Cultural note: Long history (e.g., saccharin since 1870s), with shifts in public sentiment and regulatory stance over time.

• Bottom line:

  • Safe in moderation, little evidence of harm.
  • Can help reduce "liquid calories" but are not a panacea.
  • Weight management still boils down to total calorie intake vs. expenditure.

• Dr. Russell [24:29]:

  "Artificial sweeteners are really ingrained in the fabric of our society... if I decide I'm not going to drink my soda that has 140 calories... am I then going to replace that 140 calories with chips or something else? And really with weight loss, it's math... if we're having a big double cheeseburger but we're having a diet soda with it, perhaps we're missing the point."

Notable Quotes & Memorable Moments

• On Bariatric Surgery and Remission:

  "If you're five years out from your surgery and you really have not gone back to needing diabetic medicines, you probably could talk about this as a cure."
  — Dr. John Russell [04:31]

• On New Pharmacologic Options:

  "All in all, it's a nice overview of a medicine that adds in a substantial way to our armamentarium."
  — Dr. Neil Skolnik [11:17]

• On Insulin Pens & Cost:

  "I think this is one of those issues that can be summed up with it being pennywise and pound foolish."
  — Dr. John Russell [16:33]

• On Non-Nutritive Sweeteners:

  "Artificial sweeteners... are not a panacea as well... if we're having a big double cheeseburger but we're having a diet soda with it, perhaps we're missing the point."
  — Dr. John Russell [24:29]

Timestamps for Key Segments

• Bariatric Surgery in Mild Obesity: [00:56 – 04:31]
• Exenatide Once-Weekly: [04:31 – 11:17]
• Insulin Pens for Patient Adherence: [11:17 – 16:33]
• Beta Cell Function Preservation: [16:33 – 19:33]
• Non-Nutritive Sweeteners Science Statement: [19:33 – 26:10]

Take-Home Themes

• Expanding options: New evidence may extend eligibility for surgical and pharmacologic therapies.
• Practical impact: Ease-of-use devices and careful selection of therapies can boost adherence and outcomes.
• Early intervention: Intensive initial therapy may help preserve beta cell function.
• Lifestyle and behavior: True benefit from substitutions (e.g., non-nutritive sweeteners) depends on total lifestyle change, not isolated swaps.

For more ADA journal content, visit www.diabetesjournals.org.