Diabetes Core Update – January 2016

Podcast: Diabetes Core Update
Host: American Diabetes Association
Date: December 24, 2015
Presented by: Dr. Neil Skolnick & Dr. John Russell

Episode Overview

This episode features Dr. Neil Skolnick and Dr. John Russell reviewing and discussing key articles from the American Diabetes Association’s journals. The focus is on the latest research in diabetes care, with practical implications for clinicians. Covered topics include advances in stem cell therapies for Type 1 diabetes, lifestyle modification for gestational diabetes prevention, the impact of DPP4 inhibitors on atherosclerosis, a novel basal insulin, the role of stress and depression in cardiovascular outcomes, and the metabolic consequences of prolonged sitting.

Key Discussion Points & Insights

1. Stem Cell Transplantation for Type 1 Diabetes

Article: Umbilical cord mesenchymal stromal cells with autologous bone marrow transplantation in established type 1 diabetes
Segment: [00:55–03:33]

• Study Design: Pilot randomized controlled open-label study comparing stem cell delivery to standard Type 1 diabetes care (n=42).
• Findings:
  • Metabolic measures improved in treated patients:
    • C-peptide AUC increased 105% in responders (n=20/21).
    • A1C decreased by 13% in the transplant group (to 7.5%), while it increased in controls.
    • Daily insulin requirements dropped by one-third in treated group, with no change in controls.
• Significance:
  • First of many advances suggesting potential for transformative care in Type 1 diabetes management.
• Notable Quote:

  “Stem cell research with regard to diabetes certainly seems a place where the puck is going.”
  – Dr. John Russell [03:35]

• Key Insight:
  • Challenges remain regarding delivery, production, and immune response to stem cells, but major future potential is recognized.

2. Lifestyle Modification to Prevent Gestational Diabetes

Article: The Finnish Gestational Diabetes Prevention Trial
Segment: [03:34–06:05]

• Study Design: 293 high-risk women (<20 weeks gestation) randomized to intervention (diet, physical activity counseling) or standard antenatal care.
• Findings:
  • Incidence of gestational diabetes:
    • Intervention: 13%
    • Control: 21%
  • Gestational weight gain was reduced by 0.5 kg in the intervention group.
  • Improved physical activity and diet quality reported.
• Significance:
  • Demonstrates meaningful reduction (~1/3) in gestational diabetes with feasible lifestyle intervention.
• Notable Quote:

  “...even at a protocol that was not incredibly intensive, the effect we see is a decrease of approximately one third in the development of gestational diabetes.”
  – Dr. Neil Skolnick [06:08]

• Key Insight:
  • Importance of intensive lifestyle modification, particularly given the rising rates of overweight/obese women entering pregnancy and profound long-term consequences for both mothers and children.

3. Alogliptin (DPP4 Inhibitor) and Carotid Atherosclerosis Progression

Article: Alogliptin prevents the progression of carotid atherosclerosis in patients with type 2 diabetes
Segment: [06:55–10:15]

• Study Design: 341 patients (no CVD at entry) randomized to alogliptin (n=172) or conventional therapy (n=169) for 24 months.
• Results:
  • Alogliptin produced a greater reduction in A1C (by 0.3%) compared to controls, with no increased hypoglycemia.
  • Significant decrease in carotid intima-media thickness observed in alogliptin group; slight increase in control.
• Caveats:
  • Use of carotid intima-media thickness as a surrogate endpoint is limited (USPSTF D rating).
  • Statin use under 50% in both groups; aggressive statin therapy remains standard of care.
• Notable Quote:

  “...I probably would use this particular DPP4 like you would use the other DPP4 and I would be very, very aggressive in getting any of your diabetic patients who are over the age of 40 to be on a statin.”
  – Dr. John Russell [10:16]

4. Novel Basal Insulin: Peg Lispro vs. Insulin Glargine

Article: Randomized trial comparing basal insulin PEG Lispro and insulin glargine in patients with type 2 diabetes
Segment: [10:48–12:34]

• Study Design: 466 patients randomized to peg lispro or glargine for 52 weeks.
• Results:
  • Peg lispro led to a greater reduction in A1C (-0.82% vs. -0.29%) at 26 weeks, sustained at 52 weeks.
  • More patients achieved A1C <7% in the peg lispro group.
  • Nocturnal and total hypoglycemia rates were lower with peg lispro.
  • Peg lispro was associated with higher triglycerides, transaminases, and increased liver fat.
• Key Takeaway:
  • Due to these side effects, Lilly suspended further development of peg lispro in December 2015.
• Notable Quote:

  “We really live in an exciting age with regard to drug development...drug development presents enormous challenges and with that comes responsibility and carefulness...”
  – Dr. Neal Skolnick [12:35]

5. Impact of Depression and Stress on Cardiovascular Outcomes in Diabetes

Article: Consequences and comorbidities of elevated stress and depression symptoms in cardiovascular outcomes in diabetes
Segment: [13:15–16:25]

• Study Design: 22,000 adults (approx. 4,000 with diabetes) followed for 6 years for cardiovascular events.
• Findings:
  • Depressive/stress symptoms more common in diabetes (37% vs. 30%).
  • Elevated stress or depression in diabetes:
    • Increased risk of stroke (by ~57%) and cardiovascular death (by ~53%).
    • Dual symptoms: Cardiovascular death risk more than doubled.
  • Risk lower in nondiabetic individuals with same symptoms.
• Applications:
  • Highlights need for depression screening in diabetes management (e.g. PHQ2/PHQ9 tools).
  • Suggests potential to adjust risk factor targets (e.g., lower LDL) when both conditions co-exist.
• Notable Quote:

  “...perhaps our diabetic patients should all be screened in the office with a PHQ2 to see if someone has some depression…Does this person have some depression? And can I work on this?”
  – Dr. John Russell [16:26]

6. Breaking Up Prolonged Sitting: Effects on Glucose Metabolism

Article: Breaking up prolonged sitting with standing or walking in postmenopausal women
Segment: [17:00–18:52]

• Study Design: 22 overweight/obese postmenopausal women; each completed:
  • 7.5 hours sitting vs.
  • 7.5 hours sitting interrupted every 30 min by 5 min of standing or walking.
• Results:
  • Both standing and walking significantly reduced postprandial glucose and insulin responses.
  • Improvements carried over into the next day.
  • No significant effect on triglycerides.
• Clinical Implications:
  • Regular standing or walking breaks during sedentary periods can have immediate and lasting metabolic benefits, independent of formal exercise.
• Notable Quote:

  “Separate from the amount of exercise you do, you still need to take time during long periods where you might be sedentary to get up—as was described in this study—about every half hour to stand, to walk just for five minutes to offset the negative effects of prolonged periods of sitting.”
  – Dr. Neal Skolnick [18:53]

Memorable Moments & Quotes

• Wayne Gretzky’s Perspective on Progress:
  "I don't care where the puck is, I care where the puck is going. And certainly stem cell research with regard to diabetes certainly seems a place where the puck is going."
  – Dr. John Russell [03:34]

• Practical Advice for Clinicians:
  "[W]e can do something. When patients come into their pregnancy either overweight or obese, they...should be encouraged to carry out an intensive lifestyle modification program. And now there is good hard evidence that that intensive program can make a substantial difference."
  – Dr. Neil Skolnick [06:08]

• On Depression in Diabetes:
  "[P]erhaps our diabetic patients should all be screened in the office with a PHQ2…”
  – Dr. John Russell [16:26]

• On Physical Activity:
  “Separate from the amount of exercise you do, you still need to take time during long periods where you might be sedentary to get up, as was described in this study, about every half hour to stand [or] walk just for five minutes....”
  – Dr. Neal Skolnick [18:53]

Timestamps of Major Segments

• 00:55 – Stem Cell Transplants for Type 1 Diabetes
• 03:34 – Lifestyle Modification, Gestational Diabetes Prevention
• 06:08 – Commentary on Gestational Diabetes Prevention
• 06:55 – Alogliptin and Carotid Atherosclerosis
• 10:16 – Commentary on Surrogate Markers and Statin Use
• 10:48 – Peg Lispro versus Insulin Glargine
• 12:35 – Drug Development Challenges and Peg Lispro
• 13:15 – Depression, Stress, and Cardiovascular Outcomes
• 16:26 – Commentary on Depression Treatment in Diabetes
• 17:00 – Breaking Up Prolonged Sitting: Glucose Metabolism Study
• 18:53 – Sedentary Time and Practical Takeaways

Summary

This episode delivers valuable updates for diabetes clinicians, emphasizing practical applications for current research such as integrating lifestyle interventions into regular care, the need for mental health screening in diabetic patients, and the importance of addressing sedentary behavior. The presenters maintain an upbeat, optimistic tone about the advances and challenges in diabetes care, highlighting the dynamic and rapidly evolving landscape of the field.

For access to the referenced articles, visit www.diabetesjournals.org.