Diabetes Core Update – July 2014 Episode Summary

Podcast: Diabetes Core Update
Host: American Diabetes Association
Date: June 20, 2014
Presenters: Dr. Neil Skolnik & Dr. John J. Russell
Episode Theme:
This episode delivers clinical insights and practical takeaways from recent research published in the ADA’s journals. Targeted at healthcare professionals, the hosts review six recent articles focusing on dietary interventions, patient treatment preferences, diabetes complications, insulin management, new pharmacological adjuncts, and environmental factors influencing diabetes risk.

Main Discussion Points & Insights

1. Mediterranean Diet vs. Low-Fat Diet in Newly Diagnosed Type 2 Diabetes

(Article from Diabetes Care; Segment: [00:56]–[04:22])

• Study Overview: Randomized trial comparing low-carb Mediterranean diet (N=108) to low-fat diet (N=107) in overweight, middle-aged patients newly diagnosed with type 2 diabetes, drug-naïve at baseline.
• Dietary Goals: Energy restriction (1500 kcal women, 1800 kcal men) for both groups.
• Primary Endpoints: Time to diabetes drug necessity and A1C >7%.
• Results:
  • Median time to endpoint: 2.8 years (low-fat) vs. 4.8 years (Mediterranean)
  • Hazard ratio for drug necessity: 0.68 favoring Mediterranean diet
  • Remission at 1 year: 14% (Mediterranean) vs. 4% (low-fat); at 6 years: 5% vs. 0%
• Host Commentary:
  • Dr. Russell ([04:22]): “The Mediterranean diet… is really the one that stands out as really having such a difference now in diabetes… the longest trial ever done… also for cardiovascular disease.”

Memorable Moment:

• Dr. Russell’s point about the strength and longevity of this trial and the value of looking beyond trendy diets:

  "If we're recommending people to learn something about a diet, I think maybe to stay away from the more trendy book-based diets and really get some information on the Mediterranean diet might be really helpful for our patients." ([04:22])

2. Patient Preferences for Non-Insulin Diabetes Medicines

(Systematic Review from Diabetes Care; Segment: [04:22]–[07:23])

• Study Scope: Synthesized data from ten articles (from 2800 screened) detailing patient preferences for oral diabetes medications.
• Attributes Assessed: Glycemic control, weight control/loss, administration difficulty, frequency, cost, and side effects (weight gain, GI effects, hypoglycemia).
• Key Insight: Efficacy (especially for glycemic and weight control), hypoglycemia risk, and GI side effects are major drivers of patient choice.
• Host Commentary:
  • Dr. Skolnik ([07:23]): “If you think about it… diabetes control is related to patient adherence. We have great medicines… but adherence... depending on the medicine and the study… only runs between 50% to 80%… If the patient cares more about GI side effects... prescribing a medicine that minimizes GI side effects is important.”

Notable Quote:

• “Patients get no benefit from medicines they don't take.” — Dr. Skolnik, quoting C. Everett Koop ([07:23])

3. Musculoskeletal Complications in Type 1 Diabetes

(DCCT Data Reviewed in Diabetes Care; Segment: [07:23]–[10:33])

• Focus: Prevalence and risk factors for chiroarthropathy (limited joint movement, periarticular skin thickening) after ~24 years in over 1200 patients.
• Findings:
  • Complications present in 66% of subjects
  • Strong associations: duration, A1C, age, neuropathy, retinopathy
  • No association with intensity of therapy
• Host Commentary:
  • Dr. Russell ([10:33]): “It is significant… that people who have better A1Cs have less of this, but it really does not look... that having a better A1C is super duper protective.”

Key Point:

• These complications are common but less critical motivators compared to life-threatening reasons for controlling glycemia.

4. Insulin in Ambulatory Care – Products, Guidelines, & Titration

(Clinical Diabetes Review; Segment: [10:33]–[18:23])

• Review Scope: Different types of insulin, their use, dosing, and titration in ambulatory (outpatient) settings, referencing ADA, EASD, AACE guidelines.
• Insulin Categories: Rapid, short, intermediate, long acting, premixed
• Administration Routes: Subcutaneous via pen/vial or pump; basal vs. bolus
• Guideline Recap:
  • Basal insulin as initial add-on (0.1–0.2 units/kg/day; ~10 units/day)
  • Titrate basal by 1–2 units weekly until fasting glucose controlled
  • Add bolus insulin if needed (>0.5–1 unit/kg/day, or elevated postprandial/A1C)
  • AACE details fixed/variable titration; ADA less prescriptive
  • 2013 updates: higher initial basal dose for A1C>8%; detailed prandial dosing and alternatives (GLP-1, DPP-4)

Clinical Pearls (Dr. Skolnik): ([18:23])

• Start basal when not controlled on 2–3 orals or if A1C >10%
• Start with 10 units, titrate every few days until fasting <140
• When A1C high but fasting is controlled, add bolus prior to largest meal (start with 5 units)

5. SGLT2 Inhibitor Empagliflozin Added to Insulin Regimens

(Diabetes Care Study; Segment: [18:23]–[23:33])

• Study Population: Obese type 2 diabetics inadequately controlled on multiple daily injections (MDI) of insulin (with or without metformin), mean BMI 35.
• Intervention: Randomized to empagliflozin 10mg, 25mg, or placebo for 52 weeks.
• Findings:
  • At 18 weeks: A1C drop by -0.94 (10mg) & -1.02 (25mg) vs. -0.5 (placebo).
  • At 52 weeks: further titration enhanced A1C reduction (final A1Cs 7.2–7.1).
  • Weight reduced with no increased hypoglycemia.
  • No significant increase in UTIs; mild increase in genital mycotic infections.
• Host Reflection:
  • Dr. Russell ([23:33]): “They decrease weight… you put people on insulin… potentially increase the weight… this will decrease the weight… We like medicines that will have patients lose weight… that can be used in concert with insulin and the safely can… don't cause hypoglycemia.”

6. Environmental Pollutants and Diabetes/Obesity Risk

(Diabetes Care Study; Segment: [23:33]–[26:24])

• Study Question: Do persistent organic pollutants (POPs, e.g., PCBs) relate to glucose abnormalities and adiposity?
• Design: Cross-sectional; measured serum/adipose POP levels, CT for fat distribution, oral glucose tolerance test.
• Findings:
  • POPs in serum and adipose correlated with impaired glucose tolerance and visceral adiposity.
  • Adipose POPs predicted diabetes; serum PCBs inversely related to BMI.
• Host Cautions:
  • Dr. Skolnik ([26:24]): “The authors themselves acknowledge that huge issue… this is a cross-sectional study… might simply reflect increased adipose mass in individuals, and increased adipose mass retains PCBs… So it might not be causal.”
  • Emphasizes need to interpret such findings carefully; known major risk factors like poor diet and inactivity remain most important for diabetes risk.

Memorable Quotes

• On Patient Adherence:

  “Patients get no benefit from medicines they don't take.”
  — Dr. Neil Skolnik ([07:23])

• On Mediterranean Diet’s Power:

  "If we're recommending people to learn something about a diet, I think maybe to stay away from the more trendy book-based diets and really get some information on the Mediterranean diet might be really helpful for our patients."
  — Dr. John Russell ([04:22])

• On Environmental Study Precision:

  "We want to be careful if we hear from our patients about this concern that one, this was a cross-sectional study and actually might not mean anything, and two, if it does, the degree to which these chemicals contribute is probably a great deal less than many of the known contributors..."
  — Dr. Neil Skolnik ([26:24])

Timestamps for Key Segments

• [00:56] – Introduction of articles/topics
• [00:56–04:22] – Mediterranean diet vs. low-fat diet in T2D
• [04:22–07:23] – Patient preferences for non-insulin diabetes meds
• [07:23–10:33] – Musculoskeletal complications in type 1 diabetes
• [10:33–18:23] – Insulin pharmacotherapy overview and guidelines
• [18:23–23:33] – SGLT2 inhibitor (empagliflozin) added to insulin
• [23:33–26:24] – Environmental pollutants and diabetes/obesity

Summary Takeaways

• Dietary approaches, especially a low-carb Mediterranean regimen, may delay pharmacotherapy and promote remission in new type 2 diabetes cases.
• Patient preferences matter greatly for choice and adherence to oral diabetes medications, with efficacy and side effect profiles as key drivers.
• Musculoskeletal complications (like chiroarthropathy) are common in long-term type 1 diabetes, but tight glycemic control offers only modest protection.
• Insulin therapy initiation and intensification in ambulatory care should follow simple, evidence-based titration algorithms, with newer non-insulin agents available as useful adjuncts.
• SGLT2 inhibitors (empagliflozin) offer significant glycemic benefit and promote weight loss when added to insulin, without added hypoglycemia risk.
• Environmental exposures to persistent pollutants may correlate to increased diabetes and adiposity risk, but such links are not yet proven causal—clinical focus should remain on diet and exercise.

For further information and access to original articles, visit: www.diabetesjournals.org