Diabetes Core Update – November 2014

Podcast by the American Diabetes Association
Hosts: Dr. Neil Skolnik & Dr. John Russell
Date: October 24, 2014

Episode Overview

This episode delves into five clinically significant articles from the ADA’s journals, highlighting new research and developments in diabetes care. Topics include the effects of high-intensity statin therapy, emerging combination treatments with GLP-1 agonists, practical guidance for GLP-1 use in primary care, brain imaging studies in obese adolescents, and the metabolic impacts of pistachio consumption. The hosts interpret findings for practicing clinicians, discuss implications for patient care, and comment on current and future treatment trends.

Key Discussion Points & Insights

1. High-Intensity Statin Therapy & Coronary Plaque Regression in Diabetes

Source: Diabetes Care
Segment: [00:55–03:12]

• Study assessed the impact of high-intensity statins (rosuvastatin/atorvastatin) over 24 months, using serial intravascular ultrasound to measure coronary atheroma volume (PAV).
• At baseline, diabetic patients exhibited lower LDL and HDL, but higher triglycerides and CRP, compared to non-diabetic subjects; trends persisted at follow-up.
• Regression of coronary atheroma occurred in both diabetic and non-diabetic groups, but was less pronounced in diabetics when LDL >70 mg/dL.
• When LDL was reduced below 70 mg/dL, plaque regression in diabetics matched non-diabetics, underlining the importance of aggressive LDL lowering.

Quote:

• “If we’re really looking to have some regression, probably getting [LDL] below 70.” – Dr. John Russell [03:03]

2. Liraglutide Plus Insulin Degludec: Efficacy in Type 2 Diabetes

Source: Diabetes Care
Segment: [03:13–05:40]

• 26-week double-blind trial compared degludec alone to degludec with liraglutide in patients with poorly controlled type 2 diabetes.
• Both arms used similar insulin doses (equivalent to ~45 units); participants already on metformin.
• A1C dropped by 1.9% with the combination vs. 0.9% with degludec alone.
• The combination yielded a mean weight loss of 2.7 kg, compared to no change for insulin alone.
• Hypoglycemia rates were similar (~24%), and nausea incidence was low.

Quote:

• “Here we're seeing...a very long acting insulin…along with liraglutide and we're seeing again an important contribution of the GLP1 agonists to A1C control—here about a 1% improvement. But compared to just basal insulin we see weight loss as well.” – Dr. Neil Skolnik [05:27]

3. GLP-1 Receptor Agonists in Primary Care: Practical Guidance

Source: Clinical Diabetes
Segment: [05:41–12:23]

• At the time, three GLP-1 agonists were on the market (Byetta, Bydureon, Victoza); new weekly options (albiglutide, dulaglutide) had just been approved.
• GLP-1 agonists work by:
  • Stimulating glucose-mediated insulin production
  • Delaying gastric emptying (slower carb absorption)
  • Increasing satiety (leading to weight loss)
• They typically lower A1C by 0.5–1.5%; also reduce systolic BP and triglycerides.
• GI side effects (nausea, diarrhea) are common but generally mild and transient, peaking in the first 8 weeks.
• Titration and patient education help minimize side effects; avoid injecting near large/high-fat meals.
• Injection site nodules can occur, especially with exenatide.

Quote:

• “I think a lot of exciting things about this class…namely the very effective A1C reduction…Not having hypoglycemia I think is a big thing...[and] the ability to give a shot once a week...will be a much easier sell to patients.” – Dr. John Russell [12:06]

4. Brain Responses to Food Stimuli in Obese Adolescents: fMRI Study

Source: Diabetes Care
Segment: [12:24–14:38]

• fMRI study compared 25 obese and 15 lean adolescents (ages not specified), exposing them to images of high/low-calorie foods and non-food objects after an isocaloric meal.
• Obese teens showed heightened activation in brain regions tied to reward and emotion when viewing high-calorie foods.
• Leptin levels (higher in obese youth) correlated with increased brain activation, suggesting a neurobiological basis for strong food cues and potential leptin resistance.

Quote:

• “We all experience stimuli differently…images of high caloric density foods lead to different brain responses on functional MRI in emotional and satiety-related areas of the brain in obese adolescents compared to...lean adolescents.” – Dr. Neil Skolnik [14:53]

5. Pistachio Consumption & Metabolic Outcomes in Prediabetes

Source: Diabetes Care
Segment: [14:39–18:51]

• 54 prediabetic subjects participated in a crossover study, alternating between four months on a pistachio-supplemented diet and a matched control diet.
• Pistachio intake improved fasting glucose, insulin resistance, and cardiometabolic risk markers (fibrinogen, oxidized LDL).
• Benefits appeared independent of calories, protein, fiber, or fat content.

Quote:

• “I'm not so sure...I would take this particular study and ascribe to my patients that they should particularly eat [pistachios] and forego other nuts...there are other studies that show benefits from all the different members of the NUT family.” – Dr. John Russell [18:24]

Notable Quotes & Memorable Moments

• “If we’re really looking to have some regression, probably getting [LDL] below 70.” – Dr. John Russell [03:03]
• “GLP1s...really are presenting an increasingly exciting option...in patients who are not controlled on basal insulin alone.” – Dr. Neil Skolnik [05:30]
• “Now...as we’re seeing medicines that we could use potentially once a week, I find that very exciting...” – Dr. John Russell [12:09]
• “We all experience stimuli differently…we occupy the same space but we live in different worlds.” – Dr. Neil Skolnik [14:44]
• “I'm not so sure...that [pistachios] are better than every other nut...I think nuts are good snacks for people...” – Dr. John Russell [18:24]

Timestamps for Key Segments

• Statin Therapy & Coronary Regression – [00:55–03:12]
• Degludec + Liraglutide Trial Results – [03:13–05:40]
• Practical GLP-1 Agonist Use – [05:41–12:23]
• Obesity, Leptin & Brain Imaging – [12:24–14:38]
• Pistachio Consumption & Metabolic Markers – [14:39–18:51]

Summary for Clinicians

• Aggressive LDL lowering (<70 mg/dL) with high-intensity statins is critical for achieving comparable coronary plaque regression in diabetic patients.
• Basal insulin/GLP-1 agonist combinations offer superior A1C reduction and weight loss over basal insulin alone, with similar hypoglycemia risk.
• GLP-1 agonists provide notable glycemic and cardiometabolic benefits with manageable side effects and are increasingly accessible in patient-friendly once-weekly forms.
• Obesity interventions in youth should account for altered brain responses to food cues and possible leptin resistance, requiring strategies beyond simple dietary advice.
• Nut consumption, including pistachios, may improve metabolic parameters in prediabetes but should be considered as part of an overall healthy diet.

For article links and further reading, visit: www.diabetesjournals.org