Diabetes Core Update – June 2014 (Released May 19, 2014)

Main Theme

This episode, hosted by Dr. Neil Skolnik and Dr. John J. Russell, focuses on recent, clinically relevant research articles from the ADA’s journals. Aimed at health care professionals, the discussion highlights how recent evidence informs diabetes management, especially in areas like behavioral interventions, mental health, pregnancy outcomes, beta cell function, and the role of novel pharmacologic agents in type 2 diabetes.

Key Discussion Points & Insights

1. Lifestyle Effect on Depression and Quality of Life (Look AHEAD Trial)

• Article: Diabetes Care, June Edition
• Summary: Over 5,000 overweight or obese individuals with type 2 diabetes underwent either intensive lifestyle intervention or standard diabetes education/support.
  • Participants: ~10 years follow-up, various assessments including Beck Depression Inventory and physical fitness.
  • Results:
    • Intensive lifestyle intervention group saw a 15% reduction in incidence of depression (hazard ratio: 0.85).
    • Reported better physical function, despite general decline seen in both groups.
    • No significant difference in antidepressant use between groups.
• Clinical Takeaway: Lifestyle modifications meaningfully reduce depression risk and improve quality of life, beyond just targeting glucose control.
• Notable Quote:

  "To be able to decrease by 15% the incidence of depression using lifestyle is a big deal."
  — Dr. Skolnik [03:08]

2. Depression in Adults with Type 1 Diabetes (Type 1 Diabetes Exchange Registry)

• Article: Diabetes Care, June Edition
• Summary: Explored depression prevalence and associations in adults (≥18 years) with type 1 diabetes.
  • Findings:
    • Prevalence of probable major depression ranges from 4.6% to 10.3%, based on the PHQ8 scoring.
    • Depressed individuals more likely female, non-white, lower income/education, exercised less, missed insulin doses, and had higher rates of complications (e.g., ketoacidosis, nephropathy).
    • Higher mean A1C and increased rates of acute complications in depressed individuals.
• Clinical Implications: Targeted depression screening and intervention in type 1 diabetes could impact glycemic control and reduce complications/hospitalizations.
• Memorable Moment:

  "I think this can certainly apply to both type 1 and type 2 diabetics, but certainly our type 1 diabetics are that much more at risk for kind of larger and more acute complications."
  — Dr. Russell [06:48]

3. Beta Cell Failure in Type 2 Diabetes: Mechanisms, Prevention, and Treatment

• Article: Diabetes Care, June Edition (Expert conference summary)
• Summary: Review of beta cell function decline as a central aspect of type 2 diabetes pathophysiology.
  • Genetics, epigenetics, and several mechanisms (including beta cell death) contribute.
  • Interventions like weight loss, insulin, TZDs, anti-inflammatories, and possibly bariatric surgery can temporarily improve beta cell function.
  • No long-lasting, proven strategy for preserving beta cell function; continued research needed.
• Clinical Heel: Preservation of beta cell function is a key–but as yet elusive–therapeutic goal.
• Notable Quote:

  "No one's fully figured out how to do that yet... it's an area to be aware of because we'll be hearing more about it with regard to interventions over the next few years."
  — Dr. Skolnik [09:48]

4. Trends in Diabetes and Pregnancy Incidence and Outcomes

• Article: Diabetes Care, June Edition – Ontario, Canada Cohort (1996-2010)
• Study: Population-based analysis of ~1 million pregnancies.
  • Key Findings:
    • Rates of gestational & pregestational diabetes doubled over study period.
    • Despite rising diabetes rates, congenital abnormalities fell by 23%.
    • Perinatal mortality did not improve significantly.
    • Women with pregestational diabetes had higher risks for both congenital abnormalities and perinatal mortality compared to non-diabetic mothers.
• Clinical Implications: Improved antenatal management reduces congenital anomalies but perinatal mortality remains a concern, especially in pregestational cases.
• Memorable Quote:

  "...the women who were prediabetic tended to have more congenital abnormalities and tended to have a higher perinatal mortality than the diabetic mothers. To me, this would really say that this is probably a group we need to start looking at."
  — Dr. Russell [14:25]

5. Healthy Behavior Change and Cardiovascular Outcomes in Newly Diagnosed Type 2 Diabetes (ADDITION-Cambridge Study)

• Article: Diabetes Care, June Edition
• Summary: 5-year follow-up of 867 newly diagnosed type 2 diabetics (ages 40-69) tracked physical activity, diet, and alcohol intake.
  • Risk of adverse cardiovascular outcomes was four times higher in those who failed to adopt any healthy behaviors versus those who adopted 3-4 (e.g., weight loss, increased activity, ceased smoking/drinking).
  • Direct relationship: more positive health behaviors = lower risk.
• Practice Impact: Immediate lifestyle change after diabetes diagnosis can markedly lower CV events risk.
• Notable Quote:

  "This shows that the horse is not out of the barn so that it still makes a difference."
  — Dr. Skolnik [16:18]

6. Empagliflozin as Add-on to Metformin in Type 2 Diabetes

• Article: Diabetes Care, June Edition (Randomized, placebo-controlled trial)
• Population: Patients on ≥1500 mg metformin, A1C >7%–<10%.
  • Groups: Empagliflozin 10mg, Empagliflozin 25mg, Placebo
  • Findings at 24 Weeks:
    • Mean A1C reduction: –0.13% (placebo), –0.7% (10mg), –0.77% (25mg)
    • Weight loss: up to –2.5 kg (25mg dose)
    • Modest BP reductions
    • Similar rates of UTIs vs placebo, but increased genital mycotic infections in active groups (3.7%, 4.7%), hypoglycemia rates very low.
    • In patients with very high baseline A1C (>10%), 3.2% mean reduction with 25 mg dose.
• Clinical Assessment: Empagliflozin as a second-line agent is effective, well-tolerated, and may be useful even in patients with high baseline A1C.
• Memorable Quote:

  "It seems to be meeting some of the things that I'm going to look for in an add on medicine... there does seem to be an increase in the mycotic infections, doesn't seem to be a whole lot of hypoglycemia."
  — Dr. Russell [21:21]

Timestamps for Important Segments

| Segment/topic | Time | |:----------------------------------------------------------------------|----------:| | Intro & article list | 00:54 | | Look AHEAD: Lifestyle, depression, QoL | 01:45 | | Commentary: Lifestyle and depression in diabetes | 03:08 | | Depression in Type 1 Diabetes | 04:40 | | Commentary: Screening/interventions for depression in T1DM | 06:48 | | Beta cell failure: mechanisms and prevention | 08:46 | | Commentary: Beta cell preservation in T2DM | 09:48 | | Diabetes & pregnancy: incidence and perinatal outcomes (Ontario study)| 11:56 | | Commentary: Implications of pregnancy study findings | 13:07 | | Behavior change and cardiovascular outcomes (ADDITION study) | 14:57 | | Commentary: Lifestyle change after T2DM diagnosis | 16:18 | | Empagliflozin add-on trial | 18:10 | | Commentary: Role, safety, population considerations for SGLT2 therapy | 21:21 |

Notable Quotes

• "To be able to decrease by 15% the incidence of depression using lifestyle is a big deal." — Dr. Skolnik [03:08]
• "Our type 1 diabetics are that much more at risk for kind of larger and more acute complications." — Dr. Russell [06:48]
• "No one's fully figured out how to [preserve beta cell function] yet... it's an area to be aware of because we'll be hearing more about it with regard to interventions over the next few years." — Dr. Skolnik [09:48]
• "...the women who were prediabetic tended to have more congenital abnormalities and tended to have a higher perinatal mortality than the diabetic mothers." — Dr. Russell [14:25]
• "This shows that the horse is not out of the barn so that it still makes a difference." — Dr. Skolnik [16:18]
• "It seems to be meeting some of the things that I'm going to look for in an add on medicine... there does seem to be an increase in the mycotic infections, doesn't seem to be a whole lot of hypoglycemia." — Dr. Russell [21:21]

Summary

This episode highlighted the relevance of recent research for day-to-day diabetes care:

• Intensive lifestyle interventions benefit mood and function, even when primary CV outcomes are not met.
• Depression is a significant, under-addressed comorbidity in both type 1 and type 2 diabetics and is tied to poorer outcomes.
• Beta cell preservation remains an aspirational target in therapy, driving future research and drug development.
• Despite improved congenital outcomes, perinatal mortality in diabetic pregnancies warrants further focus, especially for pregestational diabetes.
• Significant reductions in cardiovascular risk are possible with early and comprehensive lifestyle change, even after diabetes is diagnosed.
• Newer agents like empagliflozin are emerging as safe, effective add-ons to metformin, including in patients with high baseline A1C.

For article links and further information, visit: diabetesjournals.org

End of summary.