Podcast Episode Summary

Diabetes Core Update – "Diabetes is Primary Conference – Special Edition" (6/28/2013)

Main Theme:
This special edition, recorded live at the 2013 American Diabetes Association Scientific Sessions, distills essential take-home practice points from conference lecturers. The episode addresses crucial updates in diabetes management for primary care, focusing on new blood pressure recommendations, strategies for insulin intensification, and diabetic foot care and amputation prevention.

Key Discussion Points & Insights

1. Update: New Blood Pressure Recommendations

Speaker: Dr. Reinhardt (Medical Director, Johnson Memorial Diabetes Care Center; ADA Professional Standards Committee)
Timestamps: 01:38 – 03:34

• Main Change:

  • The systolic blood pressure target has been raised from <130 mmHg to <140 mmHg, while the diastolic goal remains <80 mmHg.
  • “Instead of less than 130, the new goal was less than 140. And so our new target for blood pressure 2013 is less than 140 over less than 80.” (Dr. Reinhardt, 01:48)

• Rationale:

  • The change is rooted in an evidence-based review, which showed no improved outcomes (e.g., stroke, heart disease, kidney failure) from stricter (<130) control, but greater treatment burden and side effects from more aggressive medical therapy.
  • “As we looked at the data… the people’s outcomes… are essentially the same as trying to push less than 130… but didn’t have a better outcome. So, less than 140 seems to be our new target.” (Dr. Reinhardt, 02:11)

• Practical Tip – Medication Timing:

  • Patients on multiple antihypertensives achieve better control if one medication is taken at night.
  • “There is a trial…it actually showed that when you take one of your antihypertensives at night…you get better overall blood pressure control.” (Dr. Reinhardt, 03:08)

2. Clinical Approach: Intensifying Insulin Therapy

Speaker: Dr. Eric Johnson (Assistant Medical Director, University of North Dakota; Altrudiabetes Center)
Timestamps: 03:36 – 09:06

• Simple Next Step for Basal-Only Insulin:

  • Many PCPs are comfortable with basal insulin initiation; intensification is approachable and impactful:
    • “The good second step… is to do what we call a 90-10 program…start with a single injection of a rapid acting bolus insulin with the biggest meal of the day.” (Dr. Johnson, 04:20)
    • For example, reduce basal dose by 10% and use that 10% as rapid-acting insulin with the largest meal.

• Managing Oral Agents When Advancing Insulin:

  • Discontinue TZDs (due to weight gain/edema concerns with intensive insulin) and sulfonylureas (since they target postprandial sugars, now better addressed by bolus insulin).
    • “We often stop TZDs…as they are more likely to have weight gain issues with intensive insulin… we stop the sulfonylureas.” (Dr. Johnson, 06:11)

• Moving to Multiple Daily Injections Without Carb Counting:

  • Employ a non-carb-counting method inspired by Dr. Bergenstahl:
    • Basal insulin is titrated for fasting glucose; then, split insulin 50/50 between basal and bolus.
    • Bolus doses are based on meal size (large, medium, small), not carb counting.
    • “That works pretty well and doesn’t require them to carb count.” (Dr. Johnson, 07:34)

• Practical Impact:

  • Simpler regimens can be more accessible to primary care clinicians and patients, overcoming carb-counting barriers.
    • “Carb counting is very intimidating for most primary care physicians…This approach sounds wonderful and implementable.” (Dr. Skolnik, 08:24)

3. Diabetic Foot Care & Amputation Prevention

Speaker: Dr. David Armstrong (Professor of Surgery, University of Arizona; Director, Southern Arizona Limb Salvage Alliance)
Timestamps: 09:06 – 17:19

• Disease Burden:

  • Chronic diseases, not infections, now account for the majority of global death:
    • “For the first time in human history, more people died from non-infectious diseases…than from all of the plagues in the world combined.” (Dr. Armstrong, 09:45)
  • Diabetic foot complications are common, complex, costly, and a leading cause of hospitalization.

• Core Concept – “The Gift of Pain”:

  • “People with diabetes lose the gift of pain.” (Dr. Armstrong, citing Prof. Paul Brand, 11:00)
  • This leads to unnoticed foot trauma, ulceration, infection, and high amputation risk (amputation every 20 seconds worldwide).

• Assessment Framework (“3 Questions”):

  1. Loss of Protective Sensation (neuropathy test: monofilament, touch)
     • If absent in any site, risk is elevated.
  2. Peripheral Artery Disease (pulse exam; ABI if pulses indistinct)
     • Absent pulses prompt further vascular evaluation.
  3. History of Prior Complications (ulcers, amputation, Charcot foot)
     • Any history puts patient at highest risk.
  • “…if they can’t feel one or more of those sites, that is diagnostic…they will be at higher risk for development of a wound.” (Dr. Armstrong, 12:20)
  • “Has the person had previous problems…that automatically puts them at the highest risk stratum.” (Dr. Armstrong, 13:30)

• Risk-Based Action Plan:

  • Low risk: No neuropathy or PAD – annual specialist review, daily self-checks.

  • Medium risk: Neuropathy but no PAD – review 2–3x/year, footwear education, possible orthotics.

  • High risk: PAD ± neuropathy – more frequent checks, vascular consults, possibly every few months.

  • Very high risk: Prior complications – "36 times greater risk," review every 1–2 months, in-depth specialist follow-up.

  • “Even in the most high-risk patients, every one to two months to the foot doctor…possibly also for follow-up with a vascular specialist.” (Dr. Armstrong, 16:34)

Notable Quotes

• Dr. Reinhardt [02:11]:
  “As we looked at the data and really delved deep…there’s really no great evidence to be less than 130…People had more treatment burden from being on more drugs, more side effects, but didn’t have a better outcome.”
• Dr. Johnson [04:20]:
  “A good second step to advance a program is to do what we call a 90-10 program…starting with a single injection of a rapid acting bolus insulin with the biggest meal of the day.”
• Dr. Armstrong [11:00]:
  “People with diabetes lose the gift of pain.” (quoting Prof. Paul Brand)
• Dr. Armstrong [09:45]:
  “For the first time in human history, more people died from non-infectious diseases, Neil, than from all of the plagues in the world combined.”

Timestamps for Important Segments

• 01:38: Dr. Reinhardt on new blood pressure targets and rationale
• 03:08: Nighttime dosing of blood pressure medications
• 04:20: Dr. Johnson's practical 90-10 insulin intensification strategy
• 06:11: Adjusting oral agents when intensifying insulin
• 07:34: “Non-carb counting” basal-bolus insulin regimen
• 09:45: Dr. Armstrong on the impact of chronic disease
• 11:00: “The gift of pain” and its implications for diabetic foot care
• 12:20: Three-step assessment for diabetic foot risk
• 13:30: Prior ulcer/amputation as a high-risk marker
• 14:59: Practical risk stratification and follow-up intervals

Memorable Moments

• The practical and empathic framing of neuropathy as "losing the gift of pain."
• Concrete, actionable protocols for both insulin intensification and foot risk assessment.
• Evidence-based endorsement of relaxing previously strict blood pressure targets to lessen treatment burden.

This episode arms primary care clinicians with succinct, evidence-based updates and actionable frameworks for improving diabetes care, emphasizing risk-based management and the importance of simple, implementable steps in busy practice environments.