Diabetes Core Update – April 2016

Podcast Date: March 24, 2016
Hosts: Dr. Neil Skolnik & Dr. John J. Russell
Main Theme:
This episode spotlights clinically relevant diabetes research published in ADA journals, with implications for daily clinical practice. The hosts discuss six recent studies covering topics such as fatty liver disease, lifestyle interventions in Hispanic women, bariatric surgery effects, obstructive sleep apnea, meal fat composition, and new advancements in insulin therapy.

Key Discussion Points & Insights

1. Metabolic Consequences of Fatty Liver in Type 2 Diabetes

Article: Diabetes Care
Segment: [00:55–03:09]
Key Points:

• Nonalcoholic steatohepatitis (NASH) is prevalent among obese patients with type 2 diabetes, but its direct metabolic consequences have been less clear.
• Study of 154 obese patients, divided into four groups (controls, type 2 diabetes without NAFLD, type 2 diabetes with isolated steatosis, and type 2 diabetes with NASH).
• Finding: Metabolic parameters (insulin resistance, hypertriglyceridemia, low HDL) worsen progressively with diabetes and presence of hepatic steatosis, especially pronounced in those with NASH.
• Clinical Relevance: Fatty liver is common among diabetics. Progression to NASH is linked to exacerbated metabolic dysfunction.

Memorable Quote:

“Short of weight loss, we really do not have that quintessential treatment for fatty liver... We might get to the point that there is going to be a different algorithm, and if we find someone has type 2 diabetes and fatty liver, we’re going to do X instead of Y.”
— Dr. John J. Russell ([03:09])

2. Community Health Centers Delivering Lifestyle Modifications for Hispanic Women

Article: Diabetes Care
Segment: [03:09–05:39]
Key Points:

• Study focused on Hispanic women with prediabetes randomized to either intensive lifestyle intervention or usual care.
• Intervention: 14 weeks of group sessions (food choices, behavioral change, activity), followed over a year.
• Outcomes: Intensive group lost 3.8kg; usual care gained 1.4kg. Two-hour glucose excursions improved significantly in the intensive group.
• Reductions also seen in BMI, waist circumference, and fasting insulin.

Memorable Quote:

“There’s no question when we approach patients with prediabetes with well thought out programs that have multiple contacts, we can decrease progression substantially from prediabetes to diabetes. This trial... shows that it can be done in another important population.”
— Dr. Neil Skolnik ([05:39])

3. Bariatric Surgery and Glucose Metabolism

Article: Diabetes Care (Swedish Obese Subjects Study)
Segment: [05:39–10:11]
Key Points:

• Compared restrictive surgical methods (banding, vertical banded gastroplasty) to gastric bypass, examining long-term effects on glucose metabolism.
• Over 1,000 patients at 2- and 10-year follow-ups, stratified by weight loss (%).
• Finding: Reductions in blood glucose, insulin, and insulin resistance were comparable across surgery types when stratified by the amount of weight loss, not procedure type.
• Clinical Takeaway: The extent of weight loss, not surgical technique, is what improves metabolic outcomes post-bariatric surgery.

Memorable Quote:

“It really is how much weight loss, not necessarily how you get there… Bariatric surgery is still a very exciting thing in the realm of diabetes.”
— Dr. John J. Russell ([10:11])

4. Obstructive Sleep Apnea (OSA) and Diabetes

Article: Diabetes Spectrum
Segment: [10:11–12:58]
Key Points:

• OSA is common and independently increases the risk and severity of type 2 diabetes.
• Mechanisms: intermittent hypoxia, sleep fragmentation, inflammation, and hormonal dysregulation all lead to increased insulin resistance.
• Evidence on CPAP therapy improving diabetes control remains mixed but promising; some studies show reduced insulin resistance and lower blood glucose.
• Weight loss via lifestyle interventions improves OSA severity.

Memorable Quote:

"We need to think about obstructive sleep apnea in our patients with diabetes and probably have a low threshold for sending them for evaluation... finding that they have sleep apnea can improve both their quality of life, decrease their risk of hypertension or their blood pressure, and potentially even improve their metabolic parameters."
— Dr. Neil Skolnik ([12:58])

5. Meal Fat Quality and Glucose Response

Article: Diabetes Care
Segment: [12:58–16:25]
Key Points:

• Study investigated how different types of fat (butter vs. extra-virgin olive oil) affect post-meal glucose in type 1 diabetics.
• In a high glycemic index meal, extra virgin olive oil resulted in significantly lower postprandial glucose compared to butter or low fat.
• No significant differences were observed with low glycemic index meals.
• Ties into the broader literature on benefits of the Mediterranean diet, which features olive oil.

Memorable Quote:

“Perhaps it could be the olive oil and how it impacts glycemic excursion… probably olive oil is fine and certainly is going to be much better than butter or other fat sources for our patients.”
— Dr. John J. Russell ([16:25])

6. Emerging Insulin Technologies in Diabetes Therapy

Article: Clinical Diabetes
Segment: [16:25–23:15]
Key Points:

• Insulin initiation is generally delayed in primary care, with treatment often starting at higher A1c levels (>9%) than recommended (<7%).
• Barriers include psychological resistance, misconceptions about insulin, clinical inertia, and perceived patient resistance to injection therapy.
• The new insulin glargine 300 U/mL offers a more constant pharmacokinetic profile, longer action, and reduced nocturnal hypoglycemia compared to glargine 100 U/mL.
• Basal insulin initiation and intensification remain hindered by resource constraints and clinical inertia, despite the growing number of safer, more convenient insulin options.

Memorable Quote:

“We have lots of choices with regard to medicines... It is then incumbent upon us to embrace new technologies, new developments, and move forward in a steady fashion to make sure this continues to be the best of times for our patients with diabetes.”
— Dr. Neil Skolnik ([23:15])

Notable Quotes & Memorable Moments

• On future directions for fatty liver in diabetes:
  “This is the start and the takeoff of something that we might be doing different with our patients in the future with type 2 diabetes.”
  — Dr. John J. Russell ([03:09])

• On the impact of intensive lifestyle modification:
  “... intensive lifestyle modification decreased progression to diabetes by approximately twice as much as metformin.”
  — Dr. Neil Skolnik ([05:39])

• On bariatric surgery in diabetes management:
  “Bariatric surgery... should be something that we really do not necessarily wait before we refer people on.”
  — Dr. John J. Russell ([10:11])

• On diagnosis threshold for OSA in diabetes patients:
  “We ought to have a low threshold for doing an evaluation in patients who have diabetes if we think they may also have sleep apnea.”
  — Dr. Neil Skolnik ([12:58])

• On Mediterranean diet and meal fat quality:
  “Clearly it’s something I think we should be recommending to our cardiac patients. And certainly this might be part of it... the olive oil and how it impacts glycemic excursion.”
  — Dr. John J. Russell ([16:25])

• On the paradox of diabetes care advancements:
  “It was the best of times and it was the worst of times. We are really fortunate to live in a time where we have an increasing array of choices ... but it takes over seven years on the average till a patient is started on injectable therapy. And that’s really far from ideal.”
  — Dr. Neil Skolnik ([23:15])

Timestamps for Major Segments

• 00:55 – Fatty Liver in Type 2 Diabetes
• 03:09 – Intensive Lifestyle for Hispanic Women
• 05:39 – Bariatric Surgery and Glucose Metabolism
• 10:11 – Sleep Apnea and Diabetes
• 12:58 – Dietary Fats and Glucose Response
• 16:25 – New Insulin Choices and Initiation Barriers

This episode is a concise tour of current research with practical takeaways for busy clinicians. From emerging evidence on fatty liver's metabolic dangers and the benefits of lifestyle change in diverse communities, to the egalitarian benefits of weight loss after bariatric surgery, OSA's complicity with glycemic control, and the slow adoption of revolutionary new insulin therapies—each topic is placed in the context of what it means for real-world diabetes care.