Diabetes Core Update Special Edition: Diabetes is Primary 2015, Part 3

Podcast Date: August 10, 2015
Presented by: Dr. Neil Skolnik & Dr. John Russell (Hosts)
Featured Experts:

• Dr. Jay Shubrook (Touro University California)
• Dr. Henry Rodriguez (University of South Florida Diabetes Center)
• Dr. Eric Johnson (University of North Dakota School of Medicine and Health Sciences)

Episode Overview

This special edition of the Diabetes Core Update podcast delivers highlights from the “Diabetes is Primary” conference at the ADA Scientific Sessions, held on June 6, 2015. In Part 3, the hosts interview three leading clinicians who discuss:

• Recognition and management of atypical diabetes (Dr. Jay Shubrook)
• Unique challenges in adolescent diabetes care (Dr. Henry Rodriguez)
• Practical insights on continuous glucose monitoring (CGM) and insulin pump therapy in primary care (Dr. Eric Johnson)

The episode aims to translate the latest clinical pearls, practical strategies, and evidence-based recommendations from expert sessions directly to frontline physicians and diabetes care providers.

Key Discussion Points & Insights

1. Atypical Diabetes: Recognition & Treatment

Guest: Dr. Jay Shubrook
Timestamps: 01:32–05:24

Main Points:

• Many are familiar with Type 1, Type 2, and gestational diabetes, but several atypical subtypes exist and are clinically important.
• Case-based categories covered:
  • LADA (Latent Autoimmune Diabetes in Adults):
    • An adult-onset (ages 35-50) autoimmune diabetes, often misdiagnosed as Type 2.
    • Clinical hints: Not obese, no acanthosis nigricans, negative family history, lack of diabetic dyslipidemia.
    • "LADA is really present in 10% of people who think they have type 2." — Dr. Shubrook (03:02)
  • MODY (Maturity-Onset Diabetes of the Young): Monogenic, often seen in youth but can be missed until adulthood.
  • Ketosis-Prone Type 2 Diabetes: Subgroup of T2DM that can present with DKA.
  • Double Diabetes: Co-existence of insulin resistance and autoimmunity, further blurring diagnostic lines due to rising obesity.

Importance:

• Correct diagnosis crucial: Treatment for LADA differs fundamentally; requires early insulin initiation.
• Misguided therapy (e.g., sulfonylureas) in LADA can worsen beta-cell decline and outcomes.
• "The earlier you can put someone with LADA on insulin, the better the long-term prognosis and glucose control." (04:19)

Confirmatory Workup:

• C-peptide (low in LADA/type 1 with hyperglycemia)
• Autoimmune markers: GAD, islet cell, or insulin antibodies. (04:59)

2. Diabetes in Adolescence: Navigating Developmental and Clinical Hurdles

Guest: Dr. Henry Rodriguez
Timestamps: 06:02–11:30

Main Points:

• Adolescents are uniquely challenging: balancing disease management with peer acceptance, desire for independence, and developmental turbulence.
• "The adolescent population in particular is a challenging group... at that age they obviously want to be like everybody else." — Dr. Rodriguez (06:10)
• Adherence issues are common; rapid changes in A1C may be a red flag.
• Family conflict is frequently centered around disease management rather than typical adolescent disagreements.

Strategies for Success:

• Team-based care: Engage multidisciplinary resources—social work, psychology—whenever possible.
• Adolescent buy-in: Essential for the successful adoption of technologies like insulin pumps.
  • "There are two non-negotiable conditions for going on a pump. One is that the individual has to be monitoring frequently... The second is particularly in this age group that they're willing and interested to use a pump." (09:12)
• Parental involvement: Still critical, especially for supervision—but patient (adolescent) engagement takes priority as they transition to greater self-management.

Memorable Moment:

• Adolescent “pulls the wool over his grandparents' eyes” illustrates the ongoing need for vigilance and honest communication. (10:34)

3. CGM & Insulin Pump Therapy in Primary Care: Practical Considerations

Guest: Dr. Eric Johnson
Timestamps: 12:13–17:51

Main Points:

• Increasing prevalence of pump and CGM use among primary care populations.
• Ideal candidates: Younger, motivated, technologically savvy patients (frequent smartphone/computer users), generally type 1s who strive for but do not achieve glycemic goals with MDI.
  • "People who are technologically engaged already... are the candidates who are more successful." — Dr. Johnson (13:06)
• Pumps offer “sculptable” basal insulin delivery—unlike fixed injections, basal rates can be tailored throughout the day.

Advantages:

• Glycemic control: On-the-fly adjustments improve control, especially during periods of varied activity.
  • Example: Airplane travel vs. walking in Boston—immediate basal rate adjustments (14:16–14:49).
• Prevention of hypoglycemia: Temporary basal rate reductions can preempt exercise-induced drops.
  • "I tell patients to anticipate that by about 15 minutes and maybe extend it for another hour beyond the exercise period." (15:55)
• Overall: Less hypoglycemia, reduced glycemic variability, more “time in range” when combined with CGM data (16:20).

Key Operational Pearls for Primary Care:

• Know basics: Units per carbohydrate, correction factor, basal rates, pump features (temp basal).
• Ask practical questions: Infusion set changes, insulin protection from extreme temps, troubleshooting hyperglycemia.
  • "If the primary care audience knows a few of these questions, they can actually help these patients do some problem solving." (17:51)

Notable Quotes & Memorable Moments

• Dr. Shubrook on LADA:
  “There’s actually been a scoring sheet...If they don't have physical signs of type 2, you really should consider LADA, which is really present in 10% of people who think they have type 2.” (03:02)

• Dr. Rodriguez on adolescent challenges:
  “So to be able to work with families and I think quite honestly, having a multidisciplinary team is very helpful.” (07:35)
  “If the parents think it's a great idea, but the individual is not really keen on it...that young adult, that adolescent is going to be utilizing that device pretty much 24/7. So if they don't have buy in...they're almost doomed to failure.” (09:12)

• Dr. Johnson on pumps:
  “With pumps, we can sculpt the insulin to the person’s activity, which is much better than the person having to feel the need of the insulin.” (15:21)
  “We can really target the percentage of time less than 70 by doing this as well, particularly when combined with the sensor device that's giving us a blood sugar reading every five minutes.” (16:20)

Timestamps for Major Segments

• [01:32–05:24]: Atypical Diabetes & LADA, Dr. Jay Shubrook
• [06:02–11:30]: Diabetes in Adolescents, Dr. Henry Rodriguez
• [12:13–17:51]: CGM & Pump Therapy in Primary Care, Dr. Eric Johnson

Summary

This episode underscores the importance of recognizing atypical diabetes forms (such as LADA), proactively supporting and engaging adolescents with diabetes and their families, and embracing technology (CGMs and insulin pumps) in both specialty and primary care settings. The conversations highlight that nuanced, individualized, and team-based approaches are essential to optimal diabetes outcomes—and that primary care clinicians play a pivotal, evolving role in these trends.