Diabetes Core Update – February 2015 (Released January 24, 2015)

American Diabetes Association | Hosted by Dr. Neil Skolnik & Dr. John Russell

Episode Overview

This episode of Diabetes Core Update covers five recent, clinically relevant articles from the ADA’s journals. The hosts discuss practical applications of these studies for physicians—focusing on diverse topics: community health initiatives for Latino patients, the effects of maternal exercise, optimal use of metformin in renal disease, long-term follow-up of the landmark DCCT trial, and the nuanced relationship between hypoglycemia, cardiovascular disease, and mortality.

Key Discussion Points & Insights

1. Community Health Worker Programs for Latino Patients with Diabetes

Source: Diabetes Care, Feb 2015
[01:43 – 03:07]

• Study Design: 211 adult Latinos with poorly controlled type 2 diabetes (average baseline A1C ~9.5) were randomized to standard care or a 17-session, in-home, community health worker-led program.
• Program Content: Covered diabetes complications, lifestyle, nutrition, healthy food choices, blood glucose monitoring, and medication adherence.
• Follow-Up: Measurements at 3, 6, 12, and 18 months.
• Results:
  • Significant and sustained reductions in A1C in the intervention group compared to controls:
    • 3 months: -0.42
    • 6 months: -0.47
    • 12 months: -0.57
    • 18 months: -0.55
  • No significant changes in lipids, hypertension, or weight.

Memorable Quote:
“Culturally sensitive message delivered to people by people who understand their lifestyle and challenges can often be more effective than what we do in the office.” — Dr. Neil Skolnik [03:07]

2. Maternal Exercise, Diet, and Offspring Metabolic Health (Animal Study)

Source: Diabetes, Feb 2015
[03:07 – 06:47]

• Study Design: Rat model evaluating the effects of maternal exercise (pre-conception and during gestation) on metabolic health of male offspring.
• Groups: Regular diet or high-fat diet; subdivided into exercise during/before pregnancy or sedentary.
• Results:
  • Offspring of mothers exercising both before and during gestation, even on regular chow, had better glucose tolerance, lower insulin, and lower body fat through 52 weeks.

Host Reflection:
“If we’re looking at any particular group that is most prone to make dramatic changes in their behavior, it’s pregnant women... Maybe some exercise can be part of [prenatal advice] and maybe that would help us make some imprint on the babies that are going to be born.” — Dr. John Russell [05:31]

3. Metformin Use in Type 2 Diabetes Patients with Kidney Disease

Source: JAMA, Systematic Review
[06:47 – 08:46]

• Background: Traditional contraindications for metformin in renal impairment are due to risk of lactic acidosis.
• Findings:
  • Metformin blood levels remain generally therapeutic in patients with mild-moderate CKD (GFR 30–60).
  • Lactic acidosis incidence in metformin users (3–10 per 100,000 person-years) is similar to overall diabetes population.
  • No clear evidence that metformin increases lactic acidosis risk, except possibly with GFR <30.
• Observational Data: Metformin may benefit macrovascular outcomes even in patients often labeled with “renal contraindications.”

Key Excerpt:
“There’s always been this kind of boogeyman of lactic acidosis... If you’ve taken care of diabetes for a long time and this is a side effect we’re worried about, we probably all should have seen it more. And it’s just not something people are seeing.” — Dr. John Russell [08:46]

4. DCCT 27-Year Follow-Up – Impact of Intensive Glucose Control

Sources: Diabetes (Feb 2015); JAMA (Jan 2015)
[08:46 – 12:42]

• DCCT Basics: The seminal trial establishing the value of intensive glucose control in type 1 diabetes.
• Retinopathy Results:
  • Initial 6.5 years of tight glycemic control led to persistent lower rates of retinopathy—even two decades later.
  • Demonstrated “metabolic memory” or “legacy effect.”
• Mortality Outcomes (JAMA):
  • After 27 years, intensive group had a hazard ratio for mortality of 0.67 vs. conventional group.
  • Higher A1C levels and development of albuminuria correlated with increased all-cause mortality.
  • Benefit seen even though achieved A1C was ~7%, not lower than 7% as in some later studies.

Insightful Comment:
“Even though both there was a difference between both groups for an average of six and a half years, almost 20 years later, as a result of that intensive treatment, [there’s] an improvement in retinopathy... a 33% decrease in mortality as a result of approximately six and a half years of intensive treatment.” — Dr. Neil Skolnik [12:42]

5. Hypoglycemia and Cardiovascular/Mortality Risk in Insulin-Treated Diabetes

Source: Diabetes Care
[12:42 – 16:40]

• Study Design: Retrospective UK cohort of all insulin-treated diabetes patients >30 years.
• Main Findings:
  • Hypoglycemia was associated with increased hazard ratios for both cardiovascular outcomes and all-cause mortality:
    • Type 1 diabetes:
      • Cardiovascular HR: 1.51 (with CVD), 1.61 (without CVD)
      • Mortality HR: 1.98 / 2.03
    • Type 2 diabetes:
      • Cardiovascular HR: 1.6 / 1.49
      • Mortality HR: 1.74 / 2.48

Clinical Application:
“We really need to be mindful... when we have patients on insulin, we need to teach people how to respond to hypoglycemia, the signs and symptoms, or what to do on sick days...” — Dr. John Russell [16:40]

Notable Quotes & Memorable Moments

• “The amount of improvement here was pretty remarkable... a decrease in 0.5% A1C is in the same range that we get with a lot of the newer medicines, but here... because we’re able to teach people the things they needed to know in the manner that they needed to know them.” — Dr. Neil Skolnik [03:07]
• “Maybe you should stay away from Cheetos [in pregnancy]... Maybe some exercise can be part of that and maybe that would help us make some imprint on the babies that are going to be born.” — Dr. John Russell [05:31]
• “If you’ve taken care of diabetes for a long time... we probably all should have seen [lactic acidosis] more. And it’s just not something people are seeing.” — Dr. John Russell [08:46]
• “There is a legacy effect... almost 20 years later there’s still as a result of that intensive treatment, an improvement in retinopathy.” — Dr. Neil Skolnik [12:42]
• “We really need to be mindful now... as our patient population gets older, what is our A1C target and [which] medicines cause hypoglycemia?" — Dr. John Russell [16:40]

Timestamps for Important Segments

• Community program for Latino patients: [01:43–03:07]
• Maternal exercise/offspring health (animal model): [03:07–06:47]
• Metformin in CKD systematic review: [06:47–08:46]
• DCCT 27-year follow-up (retinopathy, mortality): [08:46–12:42]
• Hypoglycemia and CVD/mortality risk: [12:42–16:40]

Conclusion

This episode emphasized the value of culturally sensitive interventions, reconsidered metformin use in mild/moderate CKD, reinforced the far-reaching benefits of early, intensive diabetes management, and highlighted the dangers of hypoglycemia in diabetes care. The clinical takeaways are immediately relevant to primary care and endocrinology, advocating for patient-centered strategies and judicious therapeutic choices.