Diabetes Core Update – April 2014 (Released March 20, 2014)

Podcast: Diabetes Core Update
Presented by: American Diabetes Association
Hosts: Dr. Neal Skolnik & Dr. John Russell
Episode Length: ~15 minutes
Audience: Practicing physicians and health care professionals

Episode Overview

This April 2014 edition of Diabetes Core Update explores recent, clinically relevant research from ADA journals, with a focus on translating new findings into real-world diabetes care. Core topics discussed include pragmatic lifestyle interventions for diabetes prevention, physical activity’s impact on mortality, pharmacological prevention of diabetes, pancreatic safety in rodent models, the relationship between subthreshold depression and diabetes, and a debate on the role of sugar in obesity.

The hosts, Dr. Neal Skolnik and Dr. John Russell, present, interpret, and contextualize each study with the intent to help clinicians apply new data into treatment strategies.

Key Discussion Points and Insights

1. Pragmatic Approaches to Diabetes Prevention

[01:50 – 02:55]

• Article: Systematic review/meta-analysis (Diabetes Care, April 2014)
• Focus: Effectiveness of real-world lifestyle interventions to prevent type 2 diabetes.
• Findings:
  • 22 studies followed >12 months, measuring weight loss and glycemic outcomes.
  • Mean weight loss with lifestyle programs: 2.12 kg at 12 months.
  • Greater adherence to guidelines associated with greater weight loss.
  • Real-world interventions achieve about half the benefit of controlled trials, but are still meaningful.
• Host Insights:
  • Dr. Skolnik ([02:55]): “We know what to do—essentially, now what we need to learn is how to do it.”
• Contextual Relevance:
  • Need to translate intensive clinical trial successes (e.g., DPP trial) into sustainable, community-based efforts.
  • Weight loss yields tangible diabetes prevention benefits: a 16% risk reduction in progression to diabetes with each 1 kg lost.

2. Physical Activity and Mortality in Diabetic Adults

[04:10 – 06:22]

• Article: Cohort analysis from Health Surveys for England & Scotland.
• Focus: Impact of exercise (walking/sports) on all-cause and cardiovascular mortality in diabetic adults aged >50.
• Findings:
  • More physical activity = reduced mortality (dose-response).
  • 26% lower all-cause mortality with “some” activity; 35% lower with activity at recommended levels.
  • No significant benefit from “domestic activity” (e.g., chores).
  • Walking (≥5 miles/week) performed as well as more vigorous exercise in reducing mortality risk.
• Host Reflections:
  • Dr. Russell ([06:22]): “For the people who don't really want to join a gym… just walking above average, probably about five miles a week, seem to do just as well as the people who had more vigorous exercise.”
  • Dr. Russell references Yogi Berra: “When you come to a fork in the road, take it.” –[06:22]
• Clinical Takeaway: Encourage patients that moderate increases in activity (like walking) provide significant health benefits.

3. Pharmacologic Diabetes Prevention: Phentermine/Topiramate

[07:00 – 09:20]

• Article: RCT on overweight/obese patients with prediabetes/metabolic syndrome, 108-week follow-up.
• Study Arms: Placebo, low-dose phentermine/topiramate-ER, high-dose phentermine/topiramate-ER—all with lifestyle advice.
• Findings:
  • Placebo: 2.5% weight loss; Low-dose: 10.9%; High-dose: 12.5%
  • Progression to diabetes reduced by 70.5% (low-dose) and 78.7% (high-dose) vs. placebo.
  • Significant improvement in glycemic control, lipids, blood pressure, waist circumference.
• Host Perspective:
  • Dr. Skolnik ([09:20]): “The use of phentermine and topiramate led to a 70 to 80% decrease in the development of diabetes, which is important, impressive and very relevant.”
  • Both hosts underscore that medication is an adjunct, not a replacement, for lifestyle – both groups received lifestyle intervention.
• Practice Implication: Medical therapy may be justified, especially for high-risk patients who struggle with lifestyle changes alone.

4. Pancreatic Lesions and GLP-1 Therapies: Lessons from Rats

[11:10 – 14:04]

• Article: Animal study (Diabetes, April) analyzing pancreatic abnormalities in diabetic and non-diabetic rats.
• Key Message: Pancreatic lesions (degeneration, inflammation, duct proliferation) commonly occur in all rats—not just those given incretin drugs.
• Implication: Concerns about GLP-1 therapies causing pancreatitis or cancer in rodents may be overstated.
• Host Take:
  • Dr. Russell ([14:04]): “A lot of the things that they were finding and attributing to these medicines were basically rat incidentalomas… this is a bit of the rat experience.”
  • Recent NEJM/FDA guidance also downplays rodent signal relevance for human safety.
• Clinician Reassurance: Do not discount GLP-1 or DPP-4 agents based solely on rodent histopathology.

5. Subthreshold Depression’s Impact on Diabetes Outcomes

[14:30 – 16:39]

• Article: 5-year community study (Quebec) on recurring mild depression in over 1,000 type 2 diabetics.
• Findings:
  • 50% experienced subthreshold depressive episodes.
  • Four or more episodes = almost triple the risk for poor function/health-related quality of life (RR 2.86).
  • Clear dose-response: more subthreshold episodes → worse outcomes.
• Host Synthesis:
  • Dr. Skolnik ([16:39]): “Prevalence in this study was up to 50% of patients, and outcomes… were significantly worse than in patients who did not have subthreshold depression.”
  • Integrated mental health in primary care improves adherence, outcomes, and even costs.
• Practice Point: Depression at any level in diabetes is a major risk for poor health—address proactively as part of comprehensive care.

6. Counterpoints on Sugar’s Role in Obesity

[18:00 – 24:50]

Point: Sugar Is Not Uniquely to Blame

• Argument: Correlation between rising sugar consumption and obesity is not definitive causation.
• Why?
  • Many cohort and RCTs adjusting for total calories find no independent sugar effect on weight gain.
  • Observational studies didn’t fully control for energy intake.
  • Dr. Skolnik ([18:45]): “While such ecological findings are intriguing, they don't define a causality.”
• Practice Note: Focus primarily on calorie excess, not demonizing single nutrients.

Counterpoint: Sugar—Especially Sugary Beverages—Drives the Obesity Epidemic

• Argument: The rise in sugar intake (notably from beverages) parallels obesity/diabetes increases.
• Memorable Statistics:
  • From 4 lbs/year (Declaration of Independence) to 120 lbs/year (2000s) U.S. sugar consumption.
  • U.S. leads world in sugar-sweetened beverage consumption; soda sizes up from 7 oz. to 16 oz.
• Recommendations:
  • Prefer water, unsweetened tea/coffee.
  • Fruit > juice; limit sweetened beverages to 6 oz/day adults, 7 oz/day kids ([21:30]).
  • Dr. Russell: “75% of the foods we eat right now contain some added sugar.” –[21:30]
• International Perspective: Mexico now surpasses U.S. in both soda and obesity rates.

Memorable Quotes

• “We know what to do—essentially, now what we need to learn is how to do it.” – Dr. Neal Skolnik, [02:55]
• "Just walking above average, probably five miles a week, seemed to do just as well as more vigorous exercise." – Dr. John Russell, [06:22]
• “The use of phentermine and topiramate led to a 70 to 80% decrease in the development of diabetes, which is important, impressive and very relevant.” – Dr. Neal Skolnik, [09:20]
• “A lot of the things that they were finding and attributing to these medicines were basically rat incidentalomas… this is a bit of the rat experience.” – Dr. John Russell, [14:04]
• “Prevalence in this study [of subthreshold depression] was up to 50% of patients… outcomes were significantly worse than in patients who did not have subthreshold depression.” – Dr. Neal Skolnik, [16:39]
• “75% of the foods we eat right now contain some added sugar.” – Dr. John Russell, [21:30]

Segment Timestamps

• Main Content Starts: [00:55]
• Diabetes Prevention in the Real World: [01:50]
• Physical Activity and Mortality: [04:10]
• Phentermine/Topiramate for Prediabetes: [07:00]
• GLP-1 Therapies & Pancreatic Lesions: [11:10]
• Subthreshold Depression in Diabetes: [14:30]
• Sugar & Obesity Debate: [18:00–24:50]

Conclusion

This episode highlights the pragmatic aspects of diabetes prevention, management, and risk mitigation, blending the latest research with actionable insights. It reinforces the role of both lifestyle and medication interventions, cautions against over-interpreting rodent data for human safety, stresses the significance of mental health in diabetes outcomes, and provides a nuanced discussion on the impact of sugar in the obesity epidemic.

For more details and access to discussed articles, visit www.diabetesjournals.org.