Diabetes Core Update – April 2025

Podcast Date: April 3, 2025
Hosts: Dr. John J. Russell & Dr. Neil Skolnik
Guests: Dr. Michael Blaha, Dr. Marie Pierre St. Orange
Overview:
This episode of Diabetes Core Update delivers succinct, practice-focused reviews of five recent studies impacting diabetes care: from statin strategies informed by coronary artery calcium scoring, to long-term quality of life after bariatric surgery, the safety of GLP-1 agonists regarding mental health, CGM access for youth with type 1 diabetes on Medicaid, and sleep’s pivotal role in the progression from gestational to type 2 diabetes.

Episode Breakdown

1. Coronary Calcium-Guided Statin Therapy in Familial CAD (JAMA)

Guest: Dr. Michael Blaha, Johns Hopkins Ciccaroni Center
[03:00–12:49]

• Background:
  Many patients present with “intermediate” cardiovascular risk (10-year risk of 7.5–20%)—especially those with a family history of premature CAD. Deciding whether to prescribe statins in these cases remains challenging.

• Study Design (COTTON-CAD Trial):

  • Conducted in Australia.
  • Enrolled middle-aged, intermediate-risk patients with family history.
  • Used coronary artery calcium (CAC) scoring to further risk-stratify.
  • Excluded patients with CAC=0 or >400 (i.e., only those with CAC>0 and ≤400 were randomized).
  • Participants were assigned to either CAC-informed and guided therapy (with education and treatment matching calcium score) or blinded usual care.

• Key Results:

  • Over 50% had CAC=0 and didn’t get statins—allowing avoidance of unnecessary meds.
  • Statin prescriptions and LDL control were higher in the CAC-informed group.
  • Significant slowing of atherosclerotic plaque progression in the CAC-guided group.
  • Dr. Blaha: “We can successfully personalize therapy, find almost three out of five patients who don't have any calcium in their arteries and potentially treat them more conservatively… and emphasizing aggressive treatment on the patients with identified atherosclerosis…” [10:13]

• Clinical Implications:

  • Personalization: Not all patients with family history inherit high risk; CAC helps avoid unnecessary statin use, focusing effort where benefit is greatest.
  • Supports “the holy grail”: Treat the right patient, with the right drug, at the right time.
  • Typical patients are in their 50s, seeking personalized risk assessment (mean age in study similar).
  • Dr. John: “This takes us one step closer to really the holy grail in medicine, which is personalized risk management… treating the right patient with the right drug at the right time.” [12:32]

2. Bariatric Surgery vs. Medical & Lifestyle Intervention: HRQoL Over 12 Years (Diabetes Care)

[12:53–15:17]

• Study: ARMS T2D Study

  • 228 adults with type 2 diabetes (T2D) and obesity.
  • Randomized to metabolic/bariatric surgery (various procedures) or medical/lifestyle intervention.
  • Follow-up: 12 years; mean entry age ~49; average BMI 36.3; mean A1C 8.7.

• Key Findings:

  • Significant improvement in physical health-related quality of life in surgery group over 12 years.
  • Surgery group had better general health, physical function, and vitality.
  • Mental health scores did not differ meaningfully between groups.
  • Greater BMI reduction and improved physical component scores correlated in surgery group.

• Practice Relevance:

  • As insurance pushback grows regarding obesity medications, long-term HRQoL data favor surgery.
  • Cost Analysis: Surgery is a one-time ~$18,000 expense versus medications at ~$1,200/month.
  • Dr. Neil: “If we’re looking at two out of five people in the United States…that we're going to put people on medications for life, maybe we really have to have a little bit of a paradigm shift looking back at bariatric surgery again.” [15:17]

3. GLP-1 Receptor Agonists and Suicide Risk (The Lancet)

[16:53–19:52]

• Study: Nationwide French case time control study.

  • Included adults who died by suicide or were hospitalized for attempt (2013–2021) and had GLP-1 RA prescription in prior 180 days.
  • Compared exposure periods before event with reference periods; controlled for confounders and used DPP4 inhibitors as negative control.

• Key Findings:

  • No evidence of increased risk of suicide or suicide attempts linked to GLP-1 RA use (Odds Ratio: 0.62).
  • Comparable findings for DPP4 inhibitors.
  • Consistent regardless of psychiatric history or obesity.

• Context & Implications:

  • Bolsters and confirms FDA’s 2024 preliminary safety review: “does not suggest a causal link.”
  • Prior large cohort and RCT studies also support psychiatric safety of GLP-1s.
  • Dr. John: “Even with this really well carried out…very large case control study, no increase and no suggestion of any increase in suicide or suicide risk…” [19:52]
  • Providers can confidently reassure patients regarding mental health risks.

4. CGM Access for Youth with T1D on Medicaid – Importance of Removing Blood Glucose Monitoring Requirement (Diabetes Care)

[20:49–23:51]

• Background:
  In most states, Medicaid requires youth with T1D to document ≥4 fingerstick checks/day before CGM approval. California eliminated this in 2019.

• Study:

  • Retrospective study of 78 youth with T1D on Medicaid, stratified by baseline SMBG frequency (<4 vs ≥4/day), followed over six months after starting CGM.

• Results:

  • CGM adherence at 3 and 6 months was similar regardless of prior SMBG frequency.
  • A1C improved in both groups, with greater improvements in those with less than 4 fingersticks/day at baseline (A1C reduction: 1.3% vs 0.4%).
  • Sustained improvements in glycemic control.

• Practice/Policy Implications:

  • Arbitrary SMBG thresholds are not predictive of CGM benefit or adherence.
  • Removing such barriers increases access and improves health—especially for children.
  • Dr. Neil: “It speaks to sometimes the non logic in the system, right, that someone has to cross a certain kind of arbitrary threshold…for children with diabetes…part of the reason for doing CGM is because [fingersticks] don't work.” [23:51]
  • Outcomes-based policy change is supported; California leads the way.

5. Poor Sleep as a Risk Factor for Type 2 Diabetes, Especially Post-Gestational Diabetes (JAMA Network Open)

Guest: Dr. Marie Pierre St. Orange, Columbia University
[26:01–32:38]

• Background:
  Short or poor quality sleep is a recognized risk factor for T2D. Study examined long-term risk among women with history of gestational diabetes, focusing on sleep characteristics.

• Key Findings:

  • Women with gestational diabetes who frequently snored and slept <7 hours/night had double the risk of future T2D compared to those with sufficient, snore-free sleep (median follow-up: 17 years).
  • Optimal sleep duration found to be 7–8 hours/night.
  • Poor sleep influences dietary choices and weight—less sleep → less healthy food choices and more intake.
  • Mechanistic insight: Sleep restriction increases reward center activation and reduces GLP-1 (in women), leading to dysregulated appetite and decision-making.

• Clinical Takeaways:

  • Sleep should be a core counseling point for women with a history of gestational diabetes, on par with diet and exercise.
  • Dr. St. Orange: “Achieving adequate sleep duration, the nadir here was seven hours…was found to be protective or reducing the risk of developing type 2 diabetes.” [28:13]
  • Dr. John: “This has direct implications to what…practicing clinicians talk to our patients about…it's not just food, it's not just exercise, as if that's not enough…now it’s sleep…” [31:43]
  • Sex differences in hormone changes with sleep—GLP-1 reduced in women, ghrelin rises in men.

Notable Quotes & Memorable Moments

• Personalized Risk Management:

  “It tells us what I think, what patients are asking for. What the patients ask me a lot is do I have plaque and what can we do about it? And what's the rationale for me to take this drug for the rest of my life?”
  — Dr. Michael Blaha [10:13]

• On Bariatric Surgery for T2D/Obesity:

  “People did better in the surgical arm versus the medication arm…maybe that we really have to have a little bit of a paradigm shift looking back at bariatric surgery again…”
  — Dr. Neil Skolnik [15:17]

• GLP-1 Agonists and Mental Health:

  “I think we can finally put this issue to rest. I don’t think there is any suggestion of an increased risk. We can be very reassured…”
  — Dr. John J. Russell [19:52]

• Removing Barriers to CGM:

  “I don't see a reason for someone who has type 1 diabetes. I don't see a reason for anyone who’s ever had DKA…If insurance wants to draw the line on [adults with T2D], I see reasons, but I don't see a reason in children with T1D…”
  — Dr. Neil Skolnik [23:51]

• On Sleep’s Role in Diabetes Risk:

  “Achieving adequate sleep duration…the nadir here was seven hours…was found to be protective or reducing the risk of developing type 2 diabetes.”
  — Dr. Marie Pierre St. Orange [28:13]
  “If you don't get adequate sleep, you're not going to be able to make healthy choices at all. We know that insufficient sleep alters decision making…”
  — Dr. Marie Pierre St. Orange [32:08]

Timestamps of Major Segments

• [03:00] – Coronary calcium scoring & statin therapy (with Dr. Blaha)
• [12:53] – Bariatric surgery vs. medical/lifestyle for T2D/obesity
• [16:53] – GLP-1 agonists and suicide risk
• [20:49] – Medicaid CGM access for youth with T1D
• [26:01] – Sleep quality, gestational diabetes & T2D risk (with Dr. St. Orange)
• [33:10] – Episode conclusion

Summary

This month’s Diabetes Core Update anchored practice-changing evidence to direct patient care and health policy. Standouts include validation for coronary calcium scoring in personalizing statin use, evidence justifying broader consideration of bariatric surgery for diabetes/obesity, strong reassurance about GLP-1 agonist psychiatric safety, a nudge to remove arbitrary restrictions to CGM access in youth, and a clarion call to consider sleep counseling as integral for women with gestational diabetes history. The episode remains highly relevant for clinicians, offering concise, actionable guidance with strong narrative clarity and direct quotes from expert guests.