Diabetes is Primary 2014 Part 2- A Diabetes Core Update Special Edition: Screening, Diabetes Survival Skills

Summary

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

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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.

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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)

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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)

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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)

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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.

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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.

Transcript

[A]

Hello, I'm Dr. Neal Skolnick, and I'd like to welcome you to a special edition of Diabetes Core Update. On this special series, we will be interviewing a number of faculty who are presenting during the American Diabetes association scientific sessions. Diabetes is primary on June 14, 2014. Today, we will be hearing highlights of a Talk given by Dr. Charles Schaefer on screening and prevention of diabetes and a talk given by Melanie Marbury on diabetes survival skills.

[B]

Charles Schaefer is a senior partner of the University Medical Group in Augusta, Georgia. Dr. Schaefer has been board certified in internal medicine, but for the last 25 years, his practice is almost exclusively focused on primary care diabetes management. He is a former contributing editor of the journal Insulin. He is on the clinical faculty of the Medical College of Georgia and is on the primary care committee of the American diabetes association. Welcome, Dr. Schaefer.

[C]

Thank you, Neil.

[B]

Today, Dr. Schaefer will be discussing screening for diabetes. Who, what, where and when, which is presented as a plenary in the diabetes primary conference. Dr. Schaefer, why should we screen for diabetes?

[C]

Well, great question, and I think there are several issues that shape our need for screening. First of all, there are literally millions of diabetic patients throughout the United States today. There are many more than that who have prediabetes or abnormalities in blood sugar control that could ultimately become diabetes. And really, frighteningly, 2 million people a year are now being diagnosed with type 2 diabetes mellitus. So the reason for screening is really to put ferret out these likely cases and these newly developing cases and bringing to bear all the tools that we have to try to produce a better outcome for these patients. I think a real sad statistic, Neil, is that in America today, we estimate somewhere around 7, maybe 8 million people with diabetes don't know that they have it. And I assure you that those are the group that really are most likely to suffer from the complications and the preventable complications of diabetes.

[B]

Sure. Seems like there's a large pool of people with potential opportunity for early diagnosis. Is there evidence that the cost of screening is offset by either a reduction in cases or in a reduction in complications?

[C]

Well, this is really an interesting area. You would just think off the top of your head, well, gee, of course screening is going to catch people early and allow us to intervene. And this is going to produce huge savings to the medical system. And unfortunately, there's not a huge body of evidence to support the notion that screening is going to in any way really diminish diabetes. Maybe we actually will get a slight reduction in number of cases with screening. But the addition trial that was published a couple of years ago showed borderline at best responses that would suggest that we're really doing anything to rather to mitigate the diabetes portion. What we can do though, is change the overall health outlook for patients, and particularly these people who are early on, people just developing the tendency toward diabetes, a condition called prediabetes, or who are early onset type 2 diabetes patients.

[B]

Yeah, I think that if we knew how to motivate people and get them to really do what we know works, exercise and lifestyle modification, probably the most exciting aspect of screening would be catching that large group with pre diabetes. And it'll be interesting to see over the next few years whether or not that actually is shown to make a difference. Can we motivate people? So if we're not decreasing, if there's not good evidence that we're decreasing diabetes, what is it that we're looking to achieve when we screen?

[C]

Well, this is the thing that's really exciting to me, Neil, and this is why I faithfully do try to screen patients in my practice and why I would suggest that every primary care provider have some systematic method worked out of trying to identify who are these pre diabetic and newly diagnosed diabetic. 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. A great study done now about a decade ago was the Norfolk Epic study. This was a large study of cancer patients in the area of Norfolk, England. And in the process of doing the study, the researchers added in a couple of extra data sets to look for what is your A1C and what is your risk of coronary disease? Or what is your incidence rather of coronary disease. And what this study showed was that as the A1C rises, even through the range of upper normal prediabetic and diabetic levels, as the A1C rises, so does the instance of coronary vascular disease. And in fact, patients in the pre diabetic state, the people with abnormal glucose metabolism who are not fully at that stage of being diagnosable as diabetes, have, have a three to four fold increased risk of coronary vascular disease. So the exciting thing is that if you can go out there and find those patients and get your radar up and get the patient's radar up so that everybody is attuned to what can we do now to make things better? We can begin to do things like effectively counsel regarding smoking, cessation we can really engage the patient in, in serious, meaningful efforts at weight reduction. We can hopefully get them to turn some attention to dietary intervention so that they can improve the diet and reduce the simple carbs and simple sugars that are so bad about raising glycemic levels. And we can get them actively engaged in an exercise program. So if we can see who in our population of patients might benefit from those changes, diet, exercise and weight management, now we've got the opportunity to maybe do something that changes the outlook. One thing that ought to change with smoking cessation, diet, exercise and weight management is one would expect a pretty significant reduction in coronary vascular disease. Of course, along with these lifestyle changes, you also would be concentrating on careful blood pressure control and careful lipid management. The population of patients with either prediabetes or newly diagnosed type 2. Additionally, we know from evidence from the Diabetes Prevention Program that patients who do intensively pursue these lifestyle changes that have prediabetes have a marked reduction in the incidence of transforming to full blown diabetes, about a 58% reduction if I remember my numbers right. So by identifying patients who are at risk for becoming diabetic, that is they already have abnormal glucose metabolism, or identifying those people who have newly diagnosed diabetes, we can really intervene in a meaningful way to reduce the risk of coronary vascular disease and probably even the risk of diabetes for these patients.

[B]

That's as good an argument for screening, Charlie, as I've ever heard. And for our listeners, just so we leave them with a clear directive, and who is it that we should be screening?

[C]

Well, you know, unfortunately Neil, as someone said one time, it's just a shame that money has so much to do with it and even screening has some cost associated. But I think a general rule, and the rule that's really subscribed to by the American Diabetes association is we really ought to screen to detect type 2 diabetes and prediabetes in asymptomatic people who are overweight or obese. That is a BMI of greater than or equal to 25, and who have one or more additional risk factors for diabetes. And again, that could be dyslipidemia, it could be strong family history, it could be pre previous gestational diabetes. So a number of other risk factors. But if you have just one additional risk factor and you're an adult who is obese or overweight, you ought to be screened regularly starting at about age 45. If the screening tests are normal, you probably want to repeat them at about three year intervals. And again, if you have A patient that should test positive, then you of course, want to engage those people in lifestyle and medical change, not only to try to prevent diabetes, but also to make sure that you're trying to reduce coronary vascular risk also.

[B]

Well, that's great. That really is a nice overview of why we should be screening the large pool of people that have diabetes that don't know it, and therefore the potential benefits of screening and some clear directive about who it is we should screen. Charlie, thanks so much for joining us.

[C]

Yeah, and Neil, let me throw in one last thing. Just a reminder to the audience. You can screen using random blood sugars, fasting blood sugars or self determined blood sugars. You can also use a 1C determination or 2 hour 75 gram oral glucose tolerance test. Any or all of these are appropriate. And Neil, with that, thank you for inviting me. I appreciate the opportunity to speak with you.

[B]

Our next talk is Dr. Melanie Mabry, who is going to talk about diabetes survival skills. Dr. Mabry is an acute care nurse practitioner in the Duke Division of Endocrinology, Metabolism and Nutrition and an assistant professor in the Duke University School of nursing. Welcome, Dr. Mabrey.

[D]

Thank you. Glad to be here.

[B]

Dr. Mabry, when you talk about and the title of the talk is Diabetes Survival Skills, what do you mean by diabetes survival skills?

[D]

Well, there's certain basics that every person with diabetes should understand about their diabetes to be able to function at the best level possible. Obviously, the more we know, the better we'll be able to function. But for a patient that's newly diagnosed, there's certain skills that we want to make sure that they have a good understanding of before they leave the office that day.

[B]

That's fantastic. I do a lot of outdoor hobby things like fishing and camping in the woods, and it's very clear that you need your basic survival skills. There's a lot more you can always learn, but you don't want to go into the woods without those basic survival skills. And we don't want our patients leaving without their diabetes survival skills. What are the most important, what is the most important survival skill a patient with new diabetes really needs to understand?

[D]

Well, I wish I could say there was one thing that was absolutely the key for every patient that we're going to see, but that's just really not the case. Meeting the patient where they are and helping them decide what's the most important thing for them to focus on and what they'd like to be able to improve is usually going to be the best start. Because if you can engage them from the very beginning with what's their interest. They're more likely to come along with the things that we'll perceive as our interest. So then we want to provide them that ongoing support and behavioral goal setting, being able to set a goal that they can meet. It may be as simple as talking about healthy eating or increasing activity, but it could be very complex topics. And patients come in with perceived ideas of who they know that's had diabetes and what they've seen happen to them. And if we haven't addressed those concerns, we're not going to get to the things that become priority for us. So that's the first thing that I feel like is most important.

[B]

That's fantastic. And that really is a theme of the conference today. 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 to really understanding how important it is to understand where a patient is at, to understand how we can help them get to where they need to be.

[D]

Exactly.

[B]

Can you just start the patient on a pill and have them exercise and lose weight? Why not?

[D]

Well, wouldn't that be great if it were that easy? And I think that's sometimes the perspective we've come from in the past. And what we really have realized is what you said. Individualization is really the key, but we really want to make sure that these patients are reaching goals and helping them be successful in their goals setting. So instead of telling them, you need to take this medication without understanding the disease process or how the medication works in, the process really gives them no meaning to the medication. So if we say, here, take this pill and eat right and exercise and come back and you'll be fine, we're not really getting them to where they need to be. We need to just make sure that they understand what's a reasonable goal, setting realistic goals, understanding their disease process, and then they'll be able to make steps towards meeting the goals that we want in the end for them.

[B]

That's fantastic. Are there safety issues that we need to address?

[D]

Anytime you're working with someone with diabetes, you really have to consider the safety issues of hypoglycemia. We want to make sure patients are safe, and in some medications, it's not nearly as critical as it is in others. We know how those medications work as we're prescribing them, but we still have to make sure every patient knows that there is still, even if a low risk, a risk of a low blood glucose. So they need to be able to prevent, recognize and then appropriately treat hypoglycemia if that were to occur.

[B]

Great point. And again, with someone with newly diagnosed diabetes, what's some other things that you want to be sure to cover at that initial appointment?

[D]

Well, I mentioned earlier that we want to make sure they understand the disease process because that's going to help them with their medications and then they also need to understand healthy eating and exercise. But other things to consider would be self blood glucose monitoring and having staggered time so that they really can get some information. I still see a number of patients who've been told to test their blood sugar every morning and they'll come in with great, halfway decent or good readings for fasting, but then their A1C comes back higher and they, I don't understand. They have never learned to stagger those times. So 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. The other things that we want to make sure is that they know where there's an approved program that they can go for ongoing education with that CDE team and what's available in their neighborhood if possible, and some basic problem solving strategies. I know this sounds like it would be a long appointment, but the goal for me is to get them to understand they have diabetes, what it is, how to test their blood sugar and what the goal of that blood sugar is, because it's amazing how many patients test and they have a blood sugar of 200 and don't realize it's bad. And then how lifestyle and medication are going to impact that blood sugar. 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.

[B]

That's a great point. And you know, really it's hard to meet a goal if you don't know what the goal is. How do you handle a patient who says that they hope they never have to take insulin? Something that I think we all commonly.

[D]

Encounter and one that when I ask that question, I'm so matter of fact with patients, because so many of my patients do need insulin even early on in the disease process. And I just let them know 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. And I tell them that most likely you're going to need additional amounts of that insulin. And being able to give you that hormone. And I once heard an endocrinologist say that she always tells her patients, meets them the very first time, if you do your job right and I do my job right, you're going to live long enough to need insulin. So it becomes very matter of fact having them understand that diabetes is progressive and they can live long and as Spock would say, live long and prosper with diabetes. But we want to make sure that they have those tools and get started with the survival skills and then get the ongoing tools to be successful. Yeah.

[B]

And it sounds to me, as I'm listening, one of the things that you're doing, which I like in the context of survival skills, is framing things in a positive light, that if you live long enough, you'll need insulin. And so insulin is a good thing. It helps you do well longer, and it's just part of the process. Well, it sounds like an absolutely wonderful talk. And thanks so much for joining us today.

[D]

Glad to be here.

[A]

That concludes this installment of the special edition of Diabetes Core Update, interviews with faculty who presented at the diabetes primary meeting at the scientific sessions this past June. Next on our special edition of Diabetes Core Update, we will hear from Dr. Eric Johnson discussing managing insulin therapy.