Prediabetes


Article Author:
Shantal Alvarez


Article Editor:
Amit Algotar


Editors In Chief:
Rhonda Coffman
Lindsay Iverson
Heather Templin


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
1/28/2019 4:33:36 PM

Introduction

Prediabetes is a precursor before the diagnosis of diabetes mellitus. Adults with prediabetes often may show no signs or symptoms of diabetes but will have blood sugar levels higher than normal. The normal blood glucose level is between 70 mg/dL to 99 mg/dL. In patients with prediabetes, you can expect to see blood glucose levels elevated between 110 mg/dL to - 125 mg/dL. However, these levels do not meet the required criteria for a diagnosis of diabetes mellitus. For this reason, many people are not aware that they are living with prediabetes.[1][2][3]

In addition to type 2 diabetes, prediabetes is a risk factor for the development of  cardiovascular disease, and stroke. Once diagnosed with prediabetes patients should be checked for progression to type 2 diabetes every one to two years. If screening is negative for prediabetes, repeat screening should be carried out every 3 years as per the United States Preventive Services Task Force (USPSTF). Lifestyle changes through improved nutrition and physical activity are the firstline treatment for preventing the transition from prediabetes to diabetes which can be as high as 70%. 

Etiology

The following factors put the patient at greater risk:

  • Overweight or obesity (especially a body mass index (BMI) greater than 25 kg/m^2)
  • Family history of diabetes mellitus (parent or sibling)
  • Diabetes during pregnancy (gestational diabetes)
  • High-risk ethnic groups: African American, Latin America, Native American, or Asian/Pacific Islander
  • Hypertension
  • Physical inactivity
  • Dyslipidemia with levels of HDL cholesterol less than 40 mg/dL (men) or less than 50 mg/dL (women) or triglycerides more than 250 mg/dL
  • Polycystic Ovarian Syndrome

Epidemiology

According to the Center for Disease Control and Prevention, about 84 million American adults are currently facing prediabetes. This equals one in three adults in America. About 90% of these adults do not know that they are currently living with prediabetes and setting themselves up for all the implications this entails. The incidence of diabetes is evidently growing at rapid rates globally. In America alone, about 1.5 million Americans are being diagnosed with diabetes every year. These increases are parallel with the rapid increases in the prevalence of obesity. Annually, diabetes remains the seventh cause of death in the United States and is currently costs about $245 billion in the United States. Due to this, preventing this trending progression should be at the top of the list as a national health focus and strategy. The focus on management and diagnostic studies should come second given that this disease is preventable.[4][5][6]

Pathophysiology

Since prediabetes is the precursor for diabetes mellitus, the pathophysiology is relatable. Hyperglycemia will cause production and release of insulin by the pancreatic beta cells. Excess insulin exposure for long periods of time diminishes the reponse of the insulin receptors the function of which is to open glucose channels leading to entry of glucose into the cells. Decreased function of the insulin receptors leads to further hyperglycemia further perpetuating the metabolic disturbance and leading to the development of not only diabetes type 2 but also metabolic syndrome. In prediabetes, this process is not to the extent of diabetes mellitus but is a first step in a metabolic cascade which has potentially dangerous consequences if not adequately addressed. Hence its imperative to start treatment at the earliest. [7] If treatment is not started or if the treatment is not adequate, adverse effects on large and small blood vessels (e.g. arteries of the cardiovascular system or retina, kidney, and nerves) may occure. 

History and Physical

In majority of the patients with prediabets do not experience any symptoms and hence appropriate screening and monitoring especially in individuals with family history is needed. In the minority of patients who do experience symptoms, they can be as follows:

  1. Increased appetite
  2. Unexplained weight loss/weight gain
  3. High BMI
  4. Weakness
  5. Fatigue
  6. Sweating
  7. Blurred vision
  8. Slow healing cuts or bruises
  9. Recurrent skin infections/gum bleeding

The single sign of prediabetes is elevated blood glucose on a blood test that is not high enough to be classified as type 2 diabetes mellitus.

Evaluation

The following tests can be used to screen for prediabetes: 

  • 12 hour Fasting blood glucose levels: Blood glucose levels fall between 100 mg/dL to 125 mg/dL, it is diagnostic of prediabetes.
  • Two-hour glucose tolerance test: this test will measure blood glucose levels before and after ingestion of 75 g of glucose solution; if the test shows blood glucose levels that fall between 140 mg/dL to 199 mg/dL, it is diagnostic of prediabetes.
  • A glycated hemoglobin test (also known as hemoglobin A1C) measures the average blood glucose level over the last 2 to 3 months. If it falls between 5.7% and 6.4%, it is diagnostic of prediabetes.
  • A random plasma glucose test measures blood glucose levels at any time; if the blood glucose levels fall between 140 mg/dL to -199 mg/dL, it may be indicative of prediabetes. This test will require a follow-up test to be accurate.

Screening should start between ages 30 to 45 and repeated at least every 3 years. In high-risk patients, you can initiate screening earlier and follow-up more frequently.[8][9]

Treatment / Management

The most important management in prediabetes is a lifestyle change and promotion of intense weight loss. Reducing weight by 7% through a low-fat diet, in addition to an exercise regimen of about 30 minutes per day, is the overall goal of management. [10][11][12]

Approximately 70% of people with prediabetes will go on to be diagnosed with diabetes mellitus. However, this is not inevitable. Prediabetes managed appropriately can prevent diabetes mellitus and lower the risk of cardiovascular disease.

Some patients will need to take some medications. These patients include those that have failed to maintain adequate lifestyle therapy or are at high-risk for developing type 2 diabetes. The most common medications used for prediabetes are metformin and acarbose, which will help prevent the development of diabetes mellitus. These two drugs have minimal side effects and work well in prediabetic patients.

Differential Diagnosis

  • Type 1 or type 2 diabetes
  • Insulin resistance
  • Metabolic syndrome

Complications

  • End stage renal disease
  • Blindness
  • Hypertension
  • Insulin resistance
  • Peripheral neuropathy
  • Limb loss

Pearls and Other Issues

Prevention is the key of prediabetes. The best preventative measures are:

  • Maintaining a diet rich in fiber
  • Exercising regularly
  • Losing weight
  • Adhering to medications prescribed by your doctor
  • Smoking cessation

Many studies suggest that a low-carbohydrate diet can help control insulin resistance, blood glucose levels, and weight issues. Consuming low sodium at levels less than 1500 mg per day, limiting alcohol to zero or one drink per day, and cutting out added sugar and unhealthy fats will also help prevent prediabetes from developing. Prediabetes is reversible and can only be managed by making these significant lifestyle changes and having physicians who know how to educate patients on adopting healthier lifestyle habits.

Enhancing Healthcare Team Outcomes

Today a great deal of effort is based on reversing the prediabetic state. This is best done in a multidisciplinary fashion that involves an endocrinologist, bariatric surgeon, dietitian, pharmacists, weight loss nurse and a physical therapist. The patient should be educated on the importance of exercise and discontinuation of smoking. Further, the blood pressure must be well controlled and the hyperlipidemia lowered. The patient must be educated on the importance of eating a healthy diet and remaining compliant with medications to lower the blood glucose and cholesterol. [13][14](Level V)

Outcomes

Many studies have sown that there is a relationship between persistently elevated blood glucose levels and risk for adverse cardiac events and death. Evidence shows that individuals with prediabetes are susceptible to many metabolic complications that may lead to blindness, stroke, heart disease, and renal failure. These individuals are also at a high risk for developing peripheral neuropathy and loss of limb. Further, the elevation of blood glucose during pregnancy also increase the risk of maternal and fetal mortality. [15][4](Level V)


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Prediabetes - Questions

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Which of the following is the most effective in delaying or preventing progression from prediabetes to diabetes mellitus type 2?



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A 55-year-old male with a past medical history of hypertension and obesity presents to the clinic for his annual physical. Upon review of his most recent blood work, his fasting blood glucose level is 120 mg/dL (normal less than 100 mg/dL, prediabetes 100 to 125 mg/dL, diabetes greater than 126 mg/dL). He is informed that he is in the prediabetic range and counseled on lifestyle changes that can help lower his blood glucose level. Which lifestyle change recommendation is most appropriate for the patient at this time?



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Prediabetes - References

References

Horstman C,Aronne L,Wing R,Ryan DH,Johnson WD, Implementing an Online Weight-Management Intervention to an Employee Population: Initial Experience with Real Appeal. Obesity (Silver Spring, Md.). 2018 Sep 27     [PubMed]
Moin T,Damschroder LJ,AuYoung M,Maciejewski ML,Havens K,Ertl K,Vasti E,Weinreb JE,Steinle NI,Billington CJ,Hughes M,Makki F,Youles B,Holleman RG,Kim HM,Kinsinger LS,Richardson CR, Results From a Trial of an Online Diabetes Prevention Program Intervention. American journal of preventive medicine. 2018 Sep 19     [PubMed]
Stepanek L,Horakova D,Nakladalova M,Cibickova L,Karasek D,Zadrazil J, Significance of prediabetes as a nosological entity. Biomedical papers of the Medical Faculty of the University Palacky, Olomouc, Czechoslovakia. 2018 Sep 24     [PubMed]
DiBonaventura M,Nicolucci A,Meincke H,Le Lay A,Fournier J, Obesity in Germany and Italy: prevalence, comorbidities, and associations with patient outcomes. ClinicoEconomics and outcomes research : CEOR. 2018     [PubMed]
Granados A,Gebremariam A,Gidding SS,Terry JG,Carr JJ,Steffen LM,Jacobs DR Jr,Lee JM, Association of abdominal muscle composition with prediabetes and diabetes: The CARDIA study. Diabetes, obesity     [PubMed]
Anothaisintawee T,Lertrattananon D,Thamakaison S,Thakkinstian A,Reutrakul S, The Relationship Among Morningness-Eveningness, Sleep Duration, Social Jetlag, and Body Mass Index in Asian Patients With Prediabetes. Frontiers in endocrinology. 2018     [PubMed]
Armato JP,DeFronzo RA,Abdul-Ghani M,Ruby RJ, Successful treatment of prediabetes in clinical practice using physiological assessment (STOP DIABETES). The lancet. Diabetes     [PubMed]
Kim SE,Castro Sweet CM,Gibson E,Madero EN,Rubino B,Morrison J,Rosen D,Imberg W,Cousineau MR, Evaluation of a digital diabetes prevention program adapted for the Medicaid population: Study design and methods for a non-randomized, controlled trial. Contemporary clinical trials communications. 2018 Jun     [PubMed]
Chen ME,Aguirre RS,Hannon TS, Methods for Measuring Risk for Type 2 Diabetes in Youth: the Oral Glucose Tolerance Test (OGTT). Current diabetes reports. 2018 Jun 16     [PubMed]
Blackett P,George M,Wilson DP, Integrating lipid screening with ideal cardiovascular health assessment in pediatric settings. Journal of clinical lipidology. 2018 Aug 29     [PubMed]
Lim WY,Ma S,Heng D,Tai ES,Khoo CM,Loh TP, Screening for diabetes with HbA1c: Test performance of HbA1c compared to fasting plasma glucose among Chinese, Malay and Indian community residents in Singapore. Scientific reports. 2018 Aug 20     [PubMed]
Kamble PS,Collins J,Harvey RA,Prewitt T,Kimball E,Deluzio T,Allen E,Bouchard JR, Understanding Prediabetes in a Medicare Advantage Population Using Data Adaptive Techniques. Population health management. 2018 Apr 12     [PubMed]
Soltero EG,Konopken YP,Olson ML,Keller CS,Castro FG,Williams AN,Patrick DL,Ayers S,Hu HH,Sandoval M,Pimentel J,Knowler WC,Frick KD,Shaibi GQ, Preventing diabetes in obese Latino youth with prediabetes: a study protocol for a randomized controlled trial. BMC public health. 2017 Mar 16     [PubMed]
Robert AA,Al Dawish MA,Braham R,Musallam MA,Al Hayek AA,Al Kahtany NH, Type 2 Diabetes Mellitus in Saudi Arabia: Major Challenges and Possible Solutions. Current diabetes reviews. 2017     [PubMed]
Bowen ME,Schmittdiel JA,Kullgren JT,Ackermann RT,O'Brien MJ, Building Toward a Population-Based Approach to Diabetes Screening and Prevention for US Adults. Current diabetes reports. 2018 Sep 19     [PubMed]

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