Diabetes Core Update – Special Edition

"Diabetes is Primary 2014 Part 2: Screening, Diabetes Survival Skills"

Episode Date: July 8, 2014
Hosts: Dr. Neil Skolnick & Dr. John J. Russell
Guests: Dr. Charles Schaefer & Dr. Melanie Mabrey

Episode Overview

This special edition of the Diabetes Core Update delivers insights from expert faculty presentations at the ADA's 2014 "Diabetes is Primary" conference. The episode focuses on two essential topics for practicing clinicians:

• Effective diabetes screening — why, for whom, and how best to implement in clinical practice
• Fundamental "diabetes survival skills" — critical education and tools for newly diagnosed patients

Both interviews offer actionable strategies and evidence-based reasoning meant to translate directly into better clinical outcomes.

Segment 1: Screening for Diabetes – Dr. Charles Schaefer

[00:48 – 11:33]

Main Discussion Points

Why Screen for Diabetes?

• There are millions of diagnosed and undiagnosed diabetics in the U.S., with an estimated 7–8 million unaware they have diabetes.
  • Dr. Schaefer:

    “There are many more than that who have prediabetes… and really, frighteningly, 2 million people a year are now being diagnosed with type 2 diabetes mellitus… In America today, we estimate somewhere around 7, maybe 8 million people with diabetes don't know that they have it.” (02:00)

• Early identification can engage patients in interventions before complications develop.

Does Screening Reduce Cases or Complications?

• The evidence for screening reducing incidence of diabetes itself is weak.
  • Dr. Schaefer:

    “Unfortunately, there's not a huge body of evidence to support the notion that screening is going to in any way really diminish diabetes… But what we can do is change the overall health outlook for patients.” (03:26)

• However, screening identifies those most at risk of complications, particularly cardiovascular disease (CVD).
• The Norfolk EPIC Study and Diabetes Prevention Program demonstrate increased CVD risk in prediabetes and the potential benefit of lifestyle changes.

Benefits of Early Identification

• Patients with prediabetes (“abnormal glucose metabolism”) have a 3–4x higher risk of coronary vascular disease.
  • Dr. Schaefer:

    “As the A1C rises, so does the incidence of coronary vascular disease… in the prediabetic state, people with abnormal glucose metabolism… have a three to four fold increased risk of coronary vascular disease.” (06:24)

• Lifestyle modifications—smoking cessation, weight loss, dietary changes, and exercise—offer tangible reductions in future complications.
• Intensive lifestyle intervention reduces progression to diabetes by ~58%.
• Screening patients provides an opportunity for earlier, more effective patient engagement and risk factor modification.

Whom Should We Screen?

• ADA Recommendations: Screen asymptomatic adults who are overweight or obese (BMI ≥25) with at least one additional risk factor (such as dyslipidemia, family history, or prior gestational diabetes).
  • Dr. Schaefer:

    “We really ought to screen to detect type 2 diabetes and prediabetes in asymptomatic people who are overweight or obese… and who have one or more additional risk factors.” (09:48)

• Begin at age 45, and if normal, repeat every three years.
• Intent: Not just to prevent diabetes, but also CVD by targeting early interventions.

Screening Methods

• Appropriate tests include random blood sugars, fasting blood sugars, self-monitoring, hemoglobin A1C, or a 2-hour 75g oral glucose tolerance test.
  • Dr. Schaefer:

    “You can screen using random blood sugars, fasting blood sugars, or self-determined blood sugars. You can also use an A1C determination or 2-hour 75 gram oral glucose tolerance test.” (11:36)

Memorable Quote

• Dr. Schaefer:

  “While we may not be able to mitigate ultimately how many people will experience diabetes, we can do a lot to change the overall health picture of patients with abnormal glucose tolerance or type 2 diabetes.” (05:23)

Segment 2: Diabetes Survival Skills – Dr. Melanie Mabrey

[12:00 – 19:46]

Main Discussion Points

What Are Diabetes Survival Skills?

• Core knowledge every new patient should have before leaving their first appointment, enabling them to function optimally with their diagnosis.
  • Dr. Mabrey:

    “There's certain basics that every person with diabetes should understand about their diabetes to be able to function at the best level possible.” (12:33)

The Importance of Individualization

• Key point: Meet patients where they are, find out what's most important to them, and frame initial education accordingly.
  • Dr. Mabrey:

    “Meeting the patient where they are and helping them decide what's the most important thing for them to focus on… is usually going to be the best start.” (13:24)

• Successful engagement relies on acknowledging patients’ perspectives and beliefs, especially regarding diabetes fears or prior family experiences.

Setting Goals and Ongoing Support

• Individualized, realistic goal setting is critical—“behavioral goal setting.”
• Providers must help patients set achievable goals and provide ongoing support.
• Avoid purely prescriptive approaches (“take this pill and exercise”); instead, ensure patients understand the disease, the rationale for interventions, and what realistic progress looks like.

Essential Survival Skills to Cover

• Disease process understanding: what diabetes is, and how it affects the body.
• Medication purpose and use: not just “take this pill”—clarify the mechanism and its importance.
• Healthy eating basics.
• Safe and effective exercise.
• Blood glucose monitoring: not just daily fasting, but also staggered times to capture the broader glycemic picture.
  • Dr. Mabrey:

    “We want to make sure they understand how the blood glucose data actually gives them direct feedback of how they can improve their blood sugar.” (16:36)

• Recognizing and managing hypoglycemia: prevention, identification, and treatment.
  • Dr. Mabrey:

    “Any time you're working with someone with diabetes, you really have to consider the safety issues of hypoglycemia.” (15:55)

• Connecting to approved education programs and Certified Diabetes Educator (CDE) teams for support.

Addressing Insulin Fears

• Many patients fear insulin initiation; providers should frame it factually and positively.
  • Dr. Mabrey:

    “Insulin is a hormone that you're not making enough of. Whether there's insulin resistance or not, they're still not making enough or their blood sugar would be controlled… If you do your job right and I do my job right, you're going to live long enough to need insulin… you can live long and as Spock would say, live long and prosper with diabetes.” (18:16)

• Key: Explain the progressive nature of Type 2 diabetes, normalize the eventual need for insulin, and reinforce that this is an expected and manageable stage, not a failure.

Memorable Quote

• Dr. Mabrey:

  “So many of those skills can actually be taught by staff within the office, but the provider has to convey the importance and really engage that patient and where they are.” (17:50)

Notable Quotes & Timestamps

• Dr. Charles Schaefer:

  “Those are the group that really are most likely to suffer from the complications and the preventable complications of diabetes.” (02:13)

• Dr. John Russell:

  “It really seems, as I'm listening to different people talk, is individualization of motivational messages, of survival skills, and of medicine selection… we've really come a long way from a purely algorithmic approach.” (14:17)

• Dr. Melanie Mabrey:

  “If you live long enough, you'll need insulin… insulin is a good thing. It helps you do well longer, and it's just part of the process.” (19:10)

Key Takeaways

• Screening remains an essential population health intervention, not just to identify diabetes but to address CVD risk and enable early, impactful patient engagement.
• Clinicians must move beyond algorithmic initiation – focus initial diabetes education around the patient’s individual needs, goals, and motivation.
• Survival skills for new patients should include: understanding the disease and medications, self-monitoring, hypoglycemia management, and access to support—not just lifestyle and medication advice.
• Framing diabetes management—and particularly the eventual use of insulin—in positive, realistic, and supportive ways encourages long-term patient success.

For more evidence and details, clinicians should review current ADA screening recommendations and connect patients to diabetes education resources as part of every new diagnosis.