Diabetes Core Update – August 2015 (Released July 24, 2015)

Overview

In this episode of Diabetes Core Update, Drs. Neil Skolnik and John J. Russell discuss six key articles from the American Diabetes Association’s clinical journals, aimed at offering practicing clinicians insights with direct application to patient care. Topics range from the influence of socioeconomic status on diabetes outcomes, to the role of vitamin D, strategies to minimize hypoglycemia, the physiological variability of weight loss, telemedicine for youth diabetes management, and the impact of exercise on type 1 diabetes.

Key Discussion Points & Insights

1. Socioeconomic Status and Outcomes in Type 1 Diabetes

[00:55–03:16]

• Study Details: Analysis of 24,947 Swedish patients with type 1 diabetes, mean age 39, followed for 6 years—examined the relationship between socioeconomic factors and rates of CVD and mortality.
• Findings:
  • Being married is associated with a 50% lower risk of death, cardiovascular death, and diabetes-related death versus being single.
  • Those in the lowest income quintiles have twice the risk of fatal/non-fatal CVD, coronary heart disease, and stroke, and three times the risk of death versus the highest quintile.
  • Individuals with college degrees saw a 33% lower risk of stroke compared to those with less education.
• Contextual Reflection:
  • “People who have more stable home lives are more likely to take better care of themselves…”
    – Clinician, [03:16]
  • Discussed access disparities in the U.S. vs. Sweden; highlighted how newer diabetes medications are less accessible to uninsured/underinsured.

2. Effect of Vitamin D Supplementation on Glycemic Control (The SUNNY Trial)

[03:32–05:34]

• Study Details: 275 non-insulin dependent type 2 diabetes patients randomized to vitamin D3 (50,000 IU/month) or placebo for 6 months; primary outcome: A1C change.
• Results:
  • No significant effect on A1C or glycemic outcomes in the overall group, despite increased vitamin D levels.
• Expert Commentary:
  • Dr. Skolnik warns against overinterpreting the value of vitamin D supplementation for glycemic control:
    “There are a lot of people out there who believe vitamin D is the cause of everything from hangnails to diabetes. But as the Wendy’s commercial said years ago, where’s the beef? We as clinicians want solid evidence.”
    – Dr. Skolnik, [05:34]
  • Suggests low vitamin D is more likely linked to unhealthy behaviors (e.g., less outdoor activity) than a direct cause of poor diabetes control.

3. Hypoglycemia Minimization in Diabetes

[05:34–11:50]

• Overview: Review of hypoglycemia classification, frequency, risk factors, and prevention strategies.
• Key Definitions:
  • Severe: Requires assistance (carbs/glucagon).
  • Documented symptomatic: Symptoms plus low glucose.
  • Asymptomatic: Low glucose, no symptoms.
• Epidemiology:
  • 30-40% of type 1 diabetics have 1-3 severe episodes/year.
  • Insulin-treated type 2 diabetics: ~⅓ of those rates.
• Physiology: As glucose falls, normal defense is decreased insulin and increased glucagon/epinephrine. In diabetes, these responses are blunted, especially with repeated hypoglycemia.
• Practice Recommendations:
  • Educate all diabetes patients about hypoglycemia.
  • Monitor for symptomatic events at every visit.
  • Adjust A1C targets and therapies (especially in patients with frequent or unrecognized hypoglycemia).
  • Favor insulin analogs, continuous glucose monitoring, and de-emphasize sulfonylureas where possible.
• Notable Commentary:
  • “Hypoglycemia can be very important…there’s an increased mortality when someone has hypoglycemia, especially elderly folks.”
    – Clinician, [11:50]
  • Emphasized individualized A1C targets, especially for older adults:
    “Are we setting an A1C goal for a 25-year-old or for a 75 or 85-year-old? They should be much different goals and that’s going to lead to a healthier population.”
    – Clinician, [11:50]

4. Individual Variability in Weight Loss: The “Thrifty Phenotype”

[13:43–14:42]

• Study Details: 15 healthy individuals confined and monitored for 77 days; measured changes in energy expenditure during caloric restriction and overfeeding.
• Findings:
  • Major inter-individual differences (>50%) in metabolic adaptation to the same calorie deficit/overfeeding.
  • Some lose less than expected due to marked reductions in metabolic rate and daily movement.
• Clinical Takeaway:
  • “That person who tells you in the office that ‘I really have decreased my caloric intake…but I’m not losing weight’ may actually be telling the truth.”
    – Dr. Skolnik, [14:42]
  • Weight loss is not purely mathematical; both metabolic adaptation and activity levels matter.
  • Recommends emphasizing increased physical activity alongside dietary change to counteract metabolic adaptation.

5. Telemedicine for Youth Diabetes: Skype vs. In-Person Behavioral Therapy

[17:00–18:52]

• Study Details: Adolescents aged 12–18 with type 1 diabetes (A1C >9%), and caregivers, randomized to family therapy via Skype or face-to-face in clinic.
• Outcomes:
  • Both groups saw significant improvements in glycemic control and adherence.
  • No difference between the delivery modes.
• Implications:
  • “Care was not necessarily better with Skype, but it was equivalent...As people are busier, this certainly seems to be a very convenient way to do the exact same thing.”
    – Dr. Russell, [18:55]
  • Telemedicine can increase access to best practices, especially for families distant from specialty care.
  • Main barrier is payor acceptance and reimbursement for virtual care.

6. Exercise and Type 1 Diabetes Outcomes

[20:00–21:22]

• Study Details: >18,000 adults (18–80) from Germany/Austria, categorized by self-reported exercise frequency.
• Findings:
  • More physical activity was associated with better A1C, lower rates of ketoacidosis, obesity (BMI), dyslipidemia, hypertension, and fewer microvascular complications (retinopathy, microalbuminuria).
• Expert Perspective:
  • “If we had one drug to give people and only one choice, it would probably be exercise.”
    – Dr. Skolnik, [21:22]
  • Exercise should be a cornerstone of diabetes care, but motivating patients remains challenging.

Notable Quotes & Memorable Moments

• Vitamin D skepticism:
  “As the Wendy’s commercial said years ago, where’s the beef? We as clinicians want solid evidence before we start using information to treat patients.”
  – Dr. Skolnik, [05:34]

• On hypoglycemia in elderly patients:
  “There’s an increased mortality when someone has hypoglycemia, especially elderly folks.”
  – Clinician, [11:50]

• Lived reality of patients with “thrifty” metabolism:
  “That person who tells you in the office that ‘I really have decreased my caloric intake…but I’m not losing weight the way I expected’ may actually be telling the truth...”
  – Dr. Skolnik, [14:42]

• Telemedicine equivalence:
  “Care was not necessarily better with Skype, but it was equivalent...for diabetic education, this could put best practices available to lots and lots of segments of the American population.”
  – Dr. Russell, [18:55]

• Value of physical activity:
  “If we had one drug to give people and only one choice, it would probably be exercise rather than a lot of the other things we prescribe.”
  – Dr. Skolnik, [21:22]

Timestamps for Important Segments

• Socioeconomic status in type 1 diabetes: [00:55–03:16]
• Vitamin D and glycemic control (SUNNY trial): [03:32–05:34]
• Minimizing hypoglycemia: [05:34–11:50]
• Thrifty phenotype and variable weight loss: [13:43–14:42]
• Skype vs. in-person therapy for youth diabetes: [17:00–18:52]
• Exercise in type 1 diabetes: [20:00–21:22]

Summary

This episode highlighted practical, evidence-based insights for diabetes clinicians:

• Social/financial resources and education protect against negative outcomes in type 1 diabetes.
• Vitamin D supplementation does not improve glycemic control in type 2 diabetes without deficiency.
• Hypoglycemia is frequent and dangerous—prevention, education, and individualized targets are essential, especially in older adults.
• Weight loss responses to diet are highly individual; exercise is a critical tool to counter adaptation.
• Telemedicine, specifically Skype, is effective for behavioral interventions in youth with type 1 diabetes and expands access.
• Exercise remains one of the most powerful interventions for improving outcomes in type 1 (and all) diabetes.

For further reference and full articles, visit www.diabetesjournals.org

Episode Tone: Clinical, focused, evidence-based, practical, with accessible and sometimes candid commentary aimed at practicing healthcare professionals.