Diabetes Core Update – January 2015

Podcast: Diabetes Core Update
Date: December 24, 2014
Hosts: Dr. Neil Skolnik & Dr. John J. Russell
Main Focus: Review and discussion of six important recent articles from ADA journals, with a focus on new approaches to weight loss, the gut microbiome, diabetes pharmacology, cardiovascular risk management, metformin and cancer risk, and the consequences of hypoglycemia-related driving policies.

Episode Overview

In this January 2015 edition, Drs. Neil Skolnik and John Russell dissect the latest clinically relevant findings in diabetes care. This fast-paced, expert-driven discussion centers on implementing novel research insights into everyday clinical practice, with the aim of optimizing the management of diabetes and its comorbidities.

Article Summaries & Key Insights

1. Internet-Based Behavioral Weight Loss Program

[01:58] – [03:22]

• Study Summary:
  154 adults (aged 18–70, BMI 25–45) were randomized to either an intensive Internet behavioral intervention (including 12 weekly videos, interactive self-monitoring, automated feedback) or to an education-only Internet group.
• Key Results:
  • At 3 and 6 months, the intensive group lost significantly more weight (5 kg vs. 1.3 kg at 3 months; 5.4 kg vs. 1.3 kg at 6 months).
  • More participants in the intervention group achieved ≥5% initial body weight loss and reported frequent use of weight control behaviors.
• Clinical Relevance:
  • Suggests online behavioral interventions can be a scalable, cost-effective method in combating obesity and diabetes.
• Notable Quote:

  "There's no question that we're going to have to figure out novel strategies in order to combat what is really the greatest epidemic of this century, obesity and diabetes. And this program seems to do it in a well thought out and cost effective manner."
  — Dr. Neil Skolnik [03:22]

2. The Microbiome, Obesity, and Type 2 Diabetes

[03:22] – [07:48]

• Study Highlights:
  • Reviews evidence that composition of gut microbiome may drive obesity, independently of caloric intake and exercise.
  • Notable finding: Obese microbiomes are more efficient at harvesting dietary energy.
  • Fecal transplantation from lean males to males with metabolic syndrome increased insulin sensitivity and microbial diversity.
• Clinical Pearls:
  • Gut flora could serve as both early markers and causal factors for obesity and type 2 diabetes.
  • Diet, antibiotics, and environmental factors may all shape the microbiome with metabolic consequences.
• Memorable Moment:

  "I do not envision a world that suddenly we take some type of probiotic tablet and it's suddenly going to... make us not want to eat Cheetos or we're going to eat Brussels sprouts because we took a certain probiotic."
  — Dr. John Russell [07:48]

3. Metformin & SGLT2 Inhibitors: Synergistic Effects in Diabetes Control

[07:48] – [10:26]

• Study Summary:
  • Examines how metformin and SGLT2 inhibitors, alone and in combination, impact glucose control in diabetic mice.
  • SGLT2 inhibitors alone lower blood glucose but increase endogenous glucose production; metformin suppresses this compensatory glucose output.
• Clinical Implication:
  • Supports rational combination therapy with these agents in diabetes management.
• Notable Quote:

  "SGLT2 eliminates blood glucose through the kidney... but that in turn increases hepatic glucose production. Metformin acts on that part of the mechanism, so the combination seems to make sense."
  — Dr. Neil Skolnik [10:26]

4. Spironolactone and Coronary Microvascular Function in Type 2 Diabetes

[10:26] – [12:52]

• Study Summary:
  • 64 T2DM patients (all on ACE inhibitors) randomized to spironolactone, hydrochlorothiazide, or placebo.
  • Spironolactone group showed significant improvement in coronary flow reserve by PET imaging after 6 months, vs. other groups.
• Cautionary Note:
  • Minimal observed hyperkalemia in the study, but real-world experience suggests clinicians must monitor electrolytes closely, especially given the use of ACE inhibitors.
• Memorable Quote:

  "On just a practical level... I've seen a heck of a lot more hyperkalemia with spironolactone. So... be a little bit mindful of electrolytes going forward."
  — Dr. John Russell [12:52]

5. Metformin and the Risk of Cancer:

[12:52] – [15:33]

• Study Summary:
  • Retrospective analysis (n>22,000, median ~5 years’ follow-up) compares incidence of cancer in T2DM patients using sulfonylurea, insulin, or other diabetes meds vs. metformin.
  • No significant reduction in cancer risk found with metformin after careful adjustment.
• Clinical Takeaway:
  • Metformin remains a first-line diabetes agent for metabolic reasons—not for cancer prevention.
• Notable Quote:

  "The link between metformin and decreased cancer risk never made complete sense to me... This study... showing no significant decrease in cancer risk with metformin."
  — Dr. Neil Skolnik [15:33]

6. Driver’s License Laws & Hypoglycemia Reporting: Danish Experience

[15:33] – [21:01]

• Study Highlights:

  • Denmark enforced stricter licensing laws for diabetics with recurrent hypoglycemia in 2012.
  • After implementation, reported hypoglycemic episodes dropped by 55% in medical records—thought to be due to underreporting out of fear of losing licenses.
  • Anonymous surveys captured much higher (and likely more accurate) rates of severe hypoglycemia.

• Broader Implications:

  • Mandates may inadvertently incentivize patients to withhold critical safety information, undermining physician-patient trust and possibly public safety.

• Notable Quotes:

  "When people see these consequences, they're less likely to be truthful with their physician... we don't just measure one indicator, but actually see what long term happens to patients."
  — Dr. John Russell [18:38]

  "...if we're going to drive them underground by feeling they're going to have their license taken away, I think there can be worse outcomes than just automobile accidents."
  — Dr. John Russell [21:01]

Conclusions

• Digital innovations in behavioral interventions have strong evidence for weight loss efficacy and scalability.
• Gut microbiome research is uncovering new mechanistic insights—clinical translation, however, is early and requires more evidence.
• Combination pharmacotherapy (metformin & SGLT2 inhibitors) is rational and mechanism-supported.
• Spironolactone may benefit cardiovascular microvasculature in T2DM, but side effects like hyperkalemia demand vigilance.
• Metformin’s cancer risk reduction remains unsubstantiated—stick to evidence-based indications.
• Regulatory efforts (e.g., licensing restrictions based on hypoglycemia) may have unintended consequences on patient honesty and safety.
• Clinical decisions must always be grounded in robust evidence and sensitive to patient behavior and safety beyond just statistical outcomes.

Useful Timestamps

• [01:58] Internet Behavioral Weight Loss Study
• [03:22] Microbiome & Obesity
• [07:48] Metformin and SGLT2 Inhibitors Study
• [10:26] Spironolactone and Coronary Flow in T2DM
• [12:52] Metformin and Cancer Risk
• [15:33] Hypoglycemia Reporting & Driver’s License Laws

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