Diabetes Core Update Podcast Summary

Episode Date: September 10, 2012
Hosts: Dr. Neil Skolnik & Dr. John J. Russell
Podcast Theme:
This episode of Diabetes Core Update presents and discusses recent clinically relevant articles from the ADA’s scientific journals, focusing on important findings in diabetes management, therapy outcomes, and emerging trends. Designed for clinicians, the discussion reviews the practical implications for patient care.

Main Discussion Points & Insights

1. Vitamin B12 Deficiency and Metformin Therapy

Source: Diabetes Care, Feb 2012
Segment: [02:06 – 03:42]

• Study Overview:
  Analysis of US adults aged 50+ (NHANES trial, n=8,400) examined the prevalence of vitamin B12 deficiency in relation to diabetes status and metformin use.
• Key Findings:
  • Biochemical B12 deficiency present in:
    • 5.8% of diabetics on metformin
    • 2.4% of diabetics not on metformin
    • 3.3% without diabetes
  • Adjusted odds ratio for B12 deficiency with metformin use: 2.92
  • B12 supplementation reduced deficiency only in non-diabetics, not in diabetics on metformin.
• Clinical Implications:
  Dr. Skolnik [03:42]:

  “The risk for B12 deficiency goes up enormously [in older patients on metformin]...our attention for it should be heightened. It wouldn’t surprise me if in the future we see recommendations about screening.”

• Takeaway:
  Routine B12 screening may be warranted for older diabetic patients on metformin, requiring future guideline updates.

2. Vitamin D Levels and Progression to Diabetes

Source: Diabetes Care – Diabetes Prevention Program data
Segment: [03:42 – 06:11]

• Study Overview:
  Looked at 2,000 prediabetic individuals’ baseline vitamin D levels and diabetes development risk.
• Key Findings:
  Highest vitamin D tertile had a 28% lower progression to diabetes.
• Caveats & Interpretation:
  Dr. Russell [06:11]:

  “I’m not sure that suddenly I’m going to...check their vitamin D level and say, well, you’re going to have diabetes because you have an elevated blood sugar already and you have a low vitamin D level...Maybe they’re outside more and walking around more and getting a little more sunshine, maybe they’re less likely to progress to have diabetes.”

• Takeaway:
  Association does not confirm causation; lifestyle may confound findings. Not recommended as a screening or predictive tool for diabetes progression.

3. Kidney as a Target for Diabetes Therapy: SGLT2 Inhibitors

Source: Diabetes Spectrum, 2012
Segment: [06:11 – 09:43]

• Study Overview:
  Review of SGLT2 inhibitors as oral diabetes medications in development, targeting renal glucose reabsorption.
• Key Findings:
  • SGLT2 inhibition reduces A1C ~0.5%
  • Combined well with metformin; did not induce much hypoglycemia.
  • Main side effect: increased urinary/genital infections, likely due to glucosuria.
• Clinical Perspective:
  Dr. Russell [09:43]:

  “You know, something that’s not ready for prime time, but potentially something that’s of interest.”

• Takeaway:
  These new agents are promising, albeit not yet mainstream due to efficacy and infection risk profile.

4. Fenofibrate Therapy in Type 2 Diabetes with Renal Impairment

Source: Diabetes Care, FIELD Study
Segment: [09:43 – 11:32]

• Study Overview:
  Assessed cardiovascular benefits and safety of fenofibrate 200mg in diabetics with moderate renal impairment (GFR 30–60 ml/min).
• Key Findings:
  • Fenofibrate reduced CV events (HR 0.89).
  • No significant adverse impact on renal function at studied doses.
• Clinical Perspective:
  Dr. Russell [11:32]:

  “I think the one thing you could take away from this trial is we’re always a little cautious in using the fibrates in someone who’s got some kidney disease...they really found that there was not a negative impact on people who had poor kidney function to a point that you really had to decrease the dose...”

• Takeaway:
  Reassures clinicians about fenofibrate use in moderate renal impairment, but statins remain first-line for most diabetics.

5. Dietary Flavonoids (Isoflavones) and Insulin Sensitivity

Source: Diabetes Care, Feb 2012
Segment: [11:32 – 14:19]

• Study Overview:
  RCT of 118 postmenopausal diabetic women: dietary flavonoid (enriched chocolate) & isoflavone supplementation over a year.
• Key Findings:
  • Improved insulin sensitivity
  • Improved cholesterol/HDL ratio and LDL levels
• Memorable Moment:
  Dr. Skolnik [14:19]:

  “The trial that you just went over gives us even more excuse to have chocolate and seems to in a puzzling way speak to what may be some of the benefits of flavonoids...On a more serious note...there are increased calories that come along with that, so it’s...hard to recommend to people as a therapeutic alternative, as likable as it may seem.”

• Takeaway:
  Flavonoids, especially from chocolate, may have metabolic benefits; caloric intake remains a limiting factor for clinical recommendation.

6. Declining Rates of Non-traumatic Lower Extremity Amputation in Diabetics

Source: Diabetes Care, Feb 2012
Segment: [14:19 – 17:49]

• Study Overview:
  US hospitalization rates for non-traumatic lower extremity amputation in diabetics (age 40+) from 1988–2008.
• Key Findings:
  • Age-adjusted rates dropped from 11/1000 (1996) to 3.9/1000 (2008) in older diabetics.
  • No significant change in non-diabetics.
• Context & Advances:
  Dr. Russell [16:46]:

  “Diabetic amputations used to be about 1 in 100 adult diabetics; now it’s about 1 in 300. We have more options with people with peripheral vascular disease. Certainly our patients with diabetes and peripheral vascular disease, we should be aiming for an LDL of less than 70.”

• Takeaway:
  There’s marked progress in reducing serious complications through better vascular management and coordinated care.

Notable Quotes

• Dr. Skolnik [03:42]:

  “The risk for B12 deficiency goes up enormously...our attention for it should be heightened.”

• Dr. Russell [06:11]:

  “I’m not sure that suddenly I’m going to...check their vitamin D level and say, well, you’re going to have diabetes because you have an elevated blood sugar already and you have a low vitamin D level.”

• Dr. Skolnik [14:19]:

  “…gives us even more excuse to have chocolate...but there are increased calories...so it’s...hard to recommend as a therapeutic alternative...”

• Dr. Russell [16:46]:

  “Diabetic amputations used to be about 1 in 100 adult diabetics; now it’s about 1 in 300...Certainly our patients with diabetes and peripheral vascular disease, we should be aiming for an LDL of less than 70.”

Timestamps for Major Topics

• [02:06] Vitamin B12 deficiency & metformin
• [03:42] Vitamin D & diabetes progression
• [06:11] Kidney as target for diabetes therapy/SGLT2 inhibitors
• [09:43] Fenofibrate in T2DM with renal impairment
• [11:32] Dietary flavonoids & insulin sensitivity
• [14:19] Declining amputation rates in diabetics

Summary

This episode offers practicing clinicians actionable insights from the ADA’s most recent studies. Notable topics included the growing relevance of screening for B12 deficiency in diabetics on metformin, the nuanced role of vitamin D in diabetes prevention (likely reflecting broader lifestyle effects), emerging therapeutic avenues targeting the kidney, cautious optimism around fenofibrate use in renally impaired diabetics, the possible (but calorie-limited) metabolic benefits from dietary flavonoids, and the heartening decline in diabetes-related amputations. Each discussed article bridges research and clinical practice, balancing enthusiasm for innovation with realistic perspectives on patient care.