Reading Time:

8 minutes

Pre-Diabetes: Looking over the fence to Diabetes Mellitus

Diabetes is a fast-growing and worldwide epidemic. We hear it all the time from all forms of media and social platforms. Yet, diabetes has not waned in recent past decades, quite the opposite. Therefore, it is logical to look at diabetes in its infancy so as to nip it in the bud. In this article, we will look at a grey area that allows for no further missteps if you wish to avoid the road to diabetes. This grey area is Pre-Diabetes, a state of certain metabolic conditions that LEADS to diabetes if nothing is done to address them.

“The prelude to diabetes is prediabetes in what can be described as a continuum from normoglycemia through worsening dysglycemia. Prediabetes is defined specifically as impaired glucose tolerance and/or impaired fasting glucose. According to the American Diabetes Association (ADA) impaired glucose tolerance (IGT) is defined as a 2-hour plasma glucose value in the 75-gram oral glucose tolerance test (OGTT) of 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L). Impaired fasting glucose (IFG) is defined as a fasting plasma glucose of 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L). Finally, prediabetes can also be defined as a hemoglobin A1c (HbA1c) of 5.7% –6.4% (39–46 mmol/mol). It bears stressing that the ADA criteria stipulate normal glucose tolerance (NGT) as a fasting glucose level less of than 100 mg/dl and a 2-hr post-load OGTT plasma glucose level of less than 140 mg/dl. In regards to using HbA1c as a diagnosis of prediabetes, it must be stressed that there are many well-characterized ‘pitfalls’ such as anemia, chronic kidney disease, and other systemic illness and hematological disorders that disrupt the reliability of HbA1c as an integrated measure of mean plasma glucose. In particular, racial and ethnic differences in the relationship between blood glucose values and HbA1c call for caution when utilizing HbA1c levels for the diagnosis of prediabetes. It is always prudent to confirm diagnosis with actual blood glucose measurements before instituting therapeutic measures. Estimates by the Centers for Disease Control and Prevention (CDC) in the United States indicated that there were ~29 million adults with diabetes and 86 million with prediabetes in 2014. Worldwide, there are more than 400 million people with prediabetes and projections indicate that more than 470 million people will have prediabetes by 2030. In addition, many studies from across the globe have pointed out that the risk of many comorbidities are the same in diabetes and prediabetes and affect all age groups.”1

An astounding amount of information has been collected about this condition thanks to the amount of well-funded scientific research centers and worldwide organizations that dedicate their daily hours to discover new developments in diabetes.  It has been overwhelmingly concluded that pre-diabetes is the greatest predictor of developing diabetes mellitus, a deadly disease that claims the lives of millions per year, according to the World Health Organization (WHO). Do not despair though, the good news as far as pre-diabetes is concerned, is that it is very much preventable.

Rise of Pre-Diabetes

Obesity and a sedentary lifestyle, two culprits who deservedly have their own place in the history of medical literature, are so permuted into our modern way of life that maintaining recommended diet and exercise regimes becomes insurmountable for people to follow through on their health goals. Where young kids and young adults were found outside playing ball, riding on their bicycles and running about, they are now found increasingly static. Even for adults, modern technology has engulfed many former forms of entertainment to attract the focus and attention of your average person. Watching television, surfing the web, investing time in social media and video games are one of many sedentary activities that are keeping millions upon millions from avoiding pre-diabetes. Not that there is any wrong with those activities medically speaking, rather, a balance should be the goal. After all, it is not necessary to exercise for hours on end every day and limit yourself to a daily carrot. Exercise should be progressively included if you are not used to it. Overall, a good number is 30 minutes’ worth of cardio though this varies from person to person.

The modern adult is a busy creature and our daily caloric needs are quite high for a mammalian being. We do not have that much time to invest in healthy and carefully planned cooking. We have deadlines and schedules to keep, add to the fact that there are so many unhealthy options in today’s food industry just a few blocks or miles away, our diet has been shot. Obesity is prevailing because the conditions are ripe for its persistent presence. Despite all the conscience raising scientific data and a myriad of great diets to choose from, we sometimes simply feel overwhelmed. Humans are hardwired to be creatures of habit. measurements is why “lose weight super-fast diets” fail to receive much recognition from nutritionists and scientists, because it is simply not sustainable in the long run. Diet fads that promise immediate weight loss, with no eye towards the future, fail to address that which matters most, that is, changing our dietary habits and physical outputs.

Insulin and glucose take the stage

If Pre-Diabetes is a precursor to full-blown diabetes mellitus, then we can measure where one stands in the diabetic discussion. Insulin is an endocrine hormone produced by the pancreas. Part of its work description is to pick up glucose molecules found in the bloodstream and chauffeur them to our cells for energy use. When we consume food, our digestive system breaks it down to usable form (glucose). When this happens, the pancreas is alerted and releases insulin. Hence, while our bodies digest food, insulin levels rise. As food becomes scarce, so does glucose and insulin diminishes with it. When someone has a diet that caused them to be obese (generally considered a BMI greater than 25) insulin is over-timing it in double shifts to handle all the glucose molecules found in the bloodstream. This leads to a curious behavior; our cells slowly become resistant to insulin. As our resistance to insulin increases, we lose our ability to control the blood glucose population and thus, high blood sugar is born.

Recognized pathophysiological defects

“FPG (fasting plasma glucose) values are determined by endogenous glucose production (EGP), which depends mostly on the liver. EGP and fasting insulin are used as markers of hepatic insulin resistance and show a strong relation with fasting glycemia. During absorption of a glucose-containing meal, changes in glucose concentrations are caused by intestinal absorption, suppression of EGP, and total body glucose uptake. EGP is greatly suppressed in people with normal glucose tolerance after glucose ingestion, whereas this suppression is less pronounced in prediabetes and diabetes. In type 2 diabetes, total body glucose disposal is decreased, and 85–90% of this impairment is related to muscle insulin resistance. If insulin secretion was able to compensate for insulin resistance perfectly, no observable changes in glucose concentration would occur. This factor means that, by definition, β-cell dysfunction is already present in the prediabetic phase. However, β-cell function cannot be characterised solely on the basis of insulin secretion without consideration of underlying insulin resistance. β cells respond to an increase in glucose concentration with a rise in insulin secretion that is dependent on whole body insulin sensitivity. Accordingly, the relation between insulin secretion and insulin sensitivity is hyperbolic, and the ratio of incremental insulin to incremental glucose divided by insulin resistance is described by a constant known as the disposition index. This index, therefore, is a measure of insulin secretion after the underlying degree of insulin resistance (higher for healthy people and lower for prediabetic and diabetic individuals) has been accounted for. Studies using different measures of β-cell function have reported severely abnormal (up to 80% decreased) insulin secretion in prediabetic people.”2

Hyperglycemia chart
Hyperglycemia chart. [3]

 

Pre-diabetes is diagnosed when a range of blood glucose and insulin levels are met but are not high enough to be considered fully expressed diabetes. Pre-diabetes is confirmed after a blood glucose test (after 8-14 hours of fasting) gives a reading between 6.0 mmol/L – 6.9 mmol/L (WHO). Diabetes is right over the fence, with the 7.0 mmol/L mark as a defining line.

Prevent Pre-Diabetes

Pre-Diabetes is the I-95 to Diabetes. They’re a condition as a result of a confluence of bio-factors that has caused the medical community and its corresponding patients much turmoil and stress. The bright side is, we have power. The choice to change our diet and go outside for a brisk walk is available every day. Working out does not have to mean a gym membership, it can mean going for a swim, hiking, bicycling, gardening, jogging/running, carpentering, having more sex with your partner (who said physical activity has to be tedious?) and the list goes on.

“Prediabetes should be treated to prevent progression to diabetes, mitigate some of the potential results of progression to diabetes, and prevent the potential effects of prediabetes itself. Most studies in this research specialty have focused on diabetes incidence in prediabetic individuals, and support the notion that lifestyle change should be the cornerstone for diabetes prevention.”4 

“There are currently four medications for treating the prediabetes subpopulation, including metformin, pioglitazone, acarbose, and liraglutide. In addition, the American Association of Clinical Endocrinologists (AACE) has also proposed three weight-loss therapies—including orlistat, lorcaserin, and phentermine/topiramate ER—to manage obesity with the goal of halting the progression of insulin resistance and type 2 diabetes.”5

 

Prediabetes Lifestyle Intervention
Prediabetes Lifestyle Intervention. [6]

 

“The combination of diet and exercise is arguably the single most important factor that could halt the progression towards type 2 diabetes in patients with prediabetes. Among the first studies to prove this was the Finnish Diabetes Prevention Study (DPS), a controlled randomized trial including 522 overweight subjects with impaired glucose tolerance who were randomized to either an intensive lifestyle intervention group or a standard-of-care control group. The intensive lifestyle intervention group received individualized dietary counseling and circuit-type resistance training and were advised to increase overall physical activity, whereas the control group received general counseling on diet and exercise along with an annual physical exam. The lifestyle intervention arm of the study was designed to be at a high intensity during the first year, followed by a maintenance period, with the goal of reducing both weight and dietary fat intake while increasing physical activity and dietary fiber. Weight reductions were measured after 1 year and at 3 years; the intervention group lost 4.5 kg and 3.5 kg while the control group lost 1.0 and 0.9 kg, respectively. Lipid and glycemic parameters showed more improvement in the intervention group, with a 58% reduction in the risk of developing diabetes compared to the control group. The subjects who were free of diabetes at the end of the intervention were followed up for an additional 3 years, and the incidence of diabetes, physical activity, and dietary intake of fiber and fat was measured. During the total 7-year follow-up period, the study concluded that the incidence of type 2 diabetes was 4.3 versus 7.4 per 100 person-years in the intervention and control group, respectively (log-rank test P = .0001), indicating a 36% reduction in relative risk.”7

This is the bottom line. This is the reality we face when we succumb to some habits. And we didn’t even scratch the surface. Diabetes can get complicated, literally. Cardiac disease, blindness, kidney failure and neurological disorders can all be ramified to if you currently suffer from Diabetes. That is why it is so important to be aggressive with prevention and take steps now if you are in a Pre-Diabetic state. We have the ability to reverse course by taking steps to improve your diet (no starving or whacky gimmicks necessary) and we have the ability to increase our physically active endeavors. So, if you find yourself looking over that fence, listen to those who have crossed over into diabetes (most notably its severe forms) when they tell us “turn around and do not come back.”

 

References

(1, 3) Prediabetes and Cardiovascular Disease: Pathophysiology and Interventions for Prevention and Risk Reduction. Brannick, B. Endocrinology and Metabolism Clinics of North America. 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806140/ 

(2, 4) Prediabetes: a high-risk state for diabetes development. Tabák, A.G., Herder, C., Rathmann, W., Brunner, E.J. & Kivimäki, M. The Lancet. 2012. https://lib.semmelweis.hu/sepub/pdf/2012/a22683128

(5, 6, 7) Prediabetes: Why Should We Care?. Zand, A., Ibrahim, K. & Patham, B. Methodist DeBakey Cardiovascular Journal. 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6369626/ 

 

María Laura Márquez
13 October, 2018

Written by

María Laura Márquez, general doctor graduated from The University of Oriente in 2018, Venezuela. My interests in the world of medicine and science, is focused on surgery and its greatest advances. Nowadays I practice my...read more:

Leave a Reply

If you would also like a response sent to your email please add it in the email box below.