Diabetes Core Update 9/15/2013 – Episode Summary

Podcast: Diabetes Core Update
Hosts: Dr. Neil Skolnik & Dr. John J. Russell
Air Date: September 18, 2013
Episode Focus: Review and discussion of five recent clinically relevant articles from ADA journals, with actionable insights for diabetes care professionals.

Episode Overview

In this episode, Dr. Neil Skolnik and Dr. John Russell review and discuss five recent research articles and statements from ADA journals. They explore the socioecologic determinants of diabetes, outcomes of bariatric surgery in moderately obese diabetics, the efficacy of meal replacement shakes and nutrition bars, progress on reaching ADA guidelines for A1C, BP, and LDL, and the growing prevalence of prediabetes in the United States.

Key Discussion Points & Insights

1. Socioecological Determinants of Prediabetes and Type 2 Diabetes

Reference: August edition, Diabetes Care
[00:55 – 05:42]

• The article examines the broader socioecologic (biological, geographic, and built environment) factors influencing diabetes and prediabetes risk.

• Dr. Skolnik: Emphasizes shift from a purely individual risk factor approach to one that integrates environmental determinants:

  • Obesity rates have skyrocketed: 1/3 adults and 15% youth in the U.S. are obese, up from 5-6% thirty years ago.
  • 35% of adults now have prediabetes; diabetes is the 7th leading cause of death and significantly increases healthcare costs.
  • Key Factors:
    • Increased caloric intake (2,400 kcal/day in 1970s → 2,600 kcal/day currently).
    • Portion sizes, food marketing, and accessibility (especially in "food deserts").
    • Sugar-sweetened beverages strongly linked to type 2 diabetes.
    • Sedentary behaviors (greater at work/home; less active transportation for children).
    • Environmental impediments to physical activity (safety, infrastructure).
  • Quote [03:32]:

    "Time spent in sedentary behaviors, whether it's at home, watching television or at work, are independent risk factors for several health outcomes including diabetes and obesity." — Dr. Skolnik

• Dr. Russell: Adds economic and societal commentary:

  • U.S. farm policy promotes cheap, high-calorie foods (e.g., soda sales profitable; little incentive to sell fruits/vegetables).
  • Food deserts and safety concerns limit access to healthy foods and physical activity in inner cities.
  • Cultural and labor changes: “Are we sitting down as families to eat meals … are we doing activities by ourselves? Instead of playing baseball, are we playing computer baseball?” [06:43]
  • Argues individual approaches alone are insufficient; advocates for systemic, public health strategies, likening needed change to fluoridating water.

2. Bariatric Surgery for Moderate Obesity and Diabetes

Reference: August 2013, Diabetes Care
[07:03 – 10:01]

• Summary of a randomized, controlled trial of 60 patients with uncontrolled type 2 diabetes (mean A1C: 9.7) and BMI >36.

• Participants randomized to:

  • Intensive medical therapy
  • Gastric bypass + intensive therapy
  • Sleeve gastrectomy + intensive therapy
  • Outcomes after 24 months:
    • Gastric bypass: mean A1C 6.7
    • Sleeve gastrectomy: mean A1C 7.1
    • Medical therapy: mean A1C 8.4
    • Greater absolute reduction in truncal fat with bypass.
    • Dramatic improvements in insulin sensitivity and beta-cell function, especially after bypass.

• Dr. Skolnik [10:01]:

  “Bariatric surgery is on the map as an option that is recommended as something that one might consider in the current standards of care for individuals with diabetes who are difficult to control on usual medicines and have a BMI greater than 35.”

• Gastric bypass yields the strongest results; sleeve gastrectomy is beneficial but comparatively less so.

3. Meal Replacement Shakes and Nutrition Bars for Weight Loss

Reference: Diabetes Spectrum
[10:36 – 14:15]

• Overview of a review article examining the effectiveness of meal replacements and nutrition bars as weight loss tools, supported by data from the National Weight Control Registry.

• Dr. Skolnik:

  • Meal replacements help by simplifying calorie control and reducing decision fatigue.
  • Sensory-specific satiety: limited food variety can reduce total food intake.
  • Multiple studies show meal replacements (used for 1-2 meals/day) are more effective for short-term weight loss than self-selected conventional diets.
  • Key result: 8% body weight loss in meal replacement group at 3 months vs. 1.5% in conventional food group.
  • Meta-analyses confirm comparable or superior efficacy for meal replacements during both weight-loss and maintenance phases.

• Dr. Russell [14:15]:

  • Notes short-term benefits, but long-term adherence is challenging.
  • Quote [14:33]:

    “I think the behavioral modification systems … that actually have people eat real food and really change people's behavior have shown that they have done better long term with weight loss versus something like Atkins or the Ornish diet, which are much more restrictive.”

  • Supports integrating meal replacements as tools, not solutions; stresses importance of sustained behavioral change.

4. Progress in Meeting ADA A1C, Blood Pressure, and LDL Goals

Reference: August 2013, Diabetes Care
[14:15 – 17:40]

• Large NHANES dataset (5,000+ adults with diabetes, 1988–2010) assessing trends for achieving ADA guideline targets:

  • A1C <7%:
    • 1988–94: 43%
    • 2007–10: 52%
  • BP <130/80 mmHg:
    • 1988: 33%
    • 2007–10: 51%
  • LDL <100 mg/dL:
    • 1988–94: 9%
    • 2007–10: 56%
  • Statin use and risk factor control improved dramatically.

• Dr. Skolnik [17:40]:

  “We've made remarkable strides in our care of both blood sugars and risk factors in patients with diabetes… The interesting question, though, is, is it now at a point where a lot of room for improvement remains, which I'm sure is true, but also the issue of individualization of goals.”

• Current standards emphasize individualized targets; not all patients should aim for A1C <7%.

5. Increasing Prevalence of Prediabetes (1999–2010)

Reference: August 2013, Diabetes Care
[18:05 – 20:22]

• 20,000 adult participants from NHANES; prediabetes defined as A1C 5.7–6.4% or fasting glucose 100–125 mg/dL.

• Prevalence of prediabetes:

  • 1999: 29%
  • 2010: 36% (Adults ≥18 years)

• Large, worrisome rise over 11 years.

• Dr. Russell [20:22]:

  “A very smart man once said, people don't change when they see the light. People change when they feel the heat. And certainly having close to a third of our adult Americans at a point that they're having pre diabetes, certainly to me is a point that we're starting to feel the heat. The question is, you know, is our society recognizing this heat enough that they're going to see the light and start making some changes?”

Notable Quotes & Memorable Moments

• “Time spent in sedentary behaviors, whether it's at home, watching television or at work, are independent risk factors for several health outcomes including diabetes and obesity.” — Dr. Neil Skolnik [03:32]
• “Are we sitting down as families to eat meals and when we're sitting down to eat meals, are we eating fresh prepared things? … Or instead of playing baseball, are we playing computer baseball?” — Dr. John Russell [06:43]
• “Bariatric surgery is on the map as an option that is recommended … for individuals with diabetes who are difficult to control on usual medicines and have a BMI greater than 35.” — Dr. Neil Skolnik [10:01]
• “I think the behavioral modification systems … that actually have people eat real food and really change people's behavior have shown that they have done better long term with weight loss…” — Dr. John Russell [14:33]
• “We've made remarkable strides in our care of both blood sugars and risk factors in patients with diabetes…” — Dr. Neil Skolnik [17:40]
• “People don't change when they see the light. People change when they feel the heat.” — Dr. John Russell [20:22]

Timestamps for Important Segments

• [00:55] – Socioecological determinants of diabetes
• [07:03] – Bariatric surgery in moderately obese diabetic patients
• [10:36] – Meal replacement shakes & nutrition bars
• [14:15] – Prevalence of meeting ADA A1C, BP, LDL goals
• [18:05] – Increasing prevalence of prediabetes in US

Episode Tone

The discussion balances measured optimism—highlighting progress in diabetes management—with concern about persistent and rising challenges. The tone is collegial, evidence-based, and practical, aimed at clinicians seeking to integrate new research insights into patient care. The hosts stress the need for both individual and systemic approaches to meaningfully address diabetes prevention and control.