13- Prediabetes

A Missed Opportunity

In our last post, we reviewed how poorly usual care protects people with type 2 diabetes and the potential of optimal medical treatment. Over the first 13 years of the diabetes study, usual care patients had two cardiovascular complications each—a heavy burden.  The best way to avoid that high rate of complications and cost is to intervene upstream with patients who are at high risk of becoming diabetic. We can easily identify these people. Approximately 88 million American adults have prediabetes. That is one in every 3 adult Americans. What’s more, more than 84% of people with prediabetes don’t know they have it. Prediabetes is diagnosed by blood tests

Diagnosing prediabetes by hemoglobin A1c (A1c) blood test

A1C below 5.7% is normal                                                                          Between 5.7 and 6.4% indicates you have prediabetes                                           6.5% or higher indicates you have diabetes

Diagnosing prediabetes by fasting blood glucose

99 mg/dL or lower is normal                                                                               100 to 125 mg/dL indicates you have prediabetes                                                              126 mg/dL or higher indicates you have diabetes

There is no such thing as mild or borderline diabetes. Even prediabetes is a significant disease. It is not nothing. A diagnosis of prediabetes means the games have begun. The first step in moving toward diabetic complications is eating addictive food that increases abdominal weight. Eating sugar and high carbohydrate foods increases resistance to insulin that is required to keep the glucose at a normal level in the blood. Patients in the early stage of prediabetes have insulin levels in the blood that may be three times normal. At the same time, the biology that damages the brain, heart, liver, and kidneys is killing cells in the pancreas that make insulin. When enough pancreas cells are killed, the body is no longer able to keep the blood sugar in the normal range and it begins to creep up. “Diabetic” complications including nerve damage and heart attack are not as common in prediabetes as in diabetes, but they happen, and they are related to the same biology. One third of patients with prediabetes already have chronic kidney disease and these conditions are related. In late-stage prediabetes, just before becoming diabetic, individuals have lost over 80% of their ability to make insulin, and have lost approximately half of their cells that make insulin. If the blood glucose and fat levels are not lowered, pancreas damage continues and ultimately the type 2 diabetic makes very little insulin, becoming more like the type 1 diabetic. The point is, these numbers are arbitrary, and the risk of diabetes begins long before the glucose goes higher than 126. The earlier we address these issues, the healthier we will be.

In the last post, we talked about early aggressive treatment producing much better results than later aggressive treatment. Prediabetes is at the other end of the spectrum from very high-risk diabetic patients with chronic kidney disease. It is the earliest opportunity to slow diabetic complications like kidney damage.

Below are the factors that mean you should be tested for prediabetes because your risk of that condition is increased.

  • Being 45 years or older

  • Having a parent, brother, or sister with type 2 diabetes

  • Being physically active less than 3 times a week

  • Ever having gestational diabetes (diabetes during pregnancy) or giving birth to a baby who weighed more than 9 pounds

  • Having polycystic ovary syndrome

  • Being overweight

Race and heritage are also a factor: African Americans, Hispanic/Latino Americans, American Indians, Pacific Islanders, and some Asian Americans are at higher risk.

Addressing prediabetes effectively need not be expensive and it is simple. Americans become diabetic because of food. That is the main thing to be addressed. The main problem is sugar and carbohydrate intake (bread, crackers, noodles, dumplings, pastries, cookies, donuts etc.) For many of us these foods are addictive, especially when combined with salt and fat. These same things increase the glucose after crossing over into diabetes and most people with poorly controlled glucose in type 2 diabetes are eating too much carbohydrate.

A story may help to make the point. Dr. Tim Noakes is a professor who teaches the benefits of exercise in South Africa and he is a serious runner. He has written two books on running and he runs marathons. He is so committed to exercise that he thinks running double marathons is the mark of the dedicated participant. You have all heard about carb loading in athletes, and Dr. Noakes advocated carb loading in his books. He walked the walk, and he was carb loading himself. Despite his extensive training program, he lost speed, gained 40 pounds, and became diabetic. He was astonished. I must say I was astonished. Dr. Noakes is a serious scientist and he studied food, exercise, and diabetes. He is intellectually honest, and he decided that he was wrong about carbohydrates and sugar. They should be restricted in patients with weight and sugar problems no matter how much they exercise. He cut back on carbs and quickly lost weight, gained speed and his sugar is very well-controlled on metformin alone. You can’t outrun a spoon!

While metformin reduces the risk of prediabetes becoming diabetes by one third, fewer than 4% of prediabetic patients take this medication. It costs $4 a month and the side effects are minimal. I have been prediabetic for 15 years. When my prediabetes began, I weighed 307 pounds and my fasting glucose was 107. By avoiding additive, prepared foods that combine fat, salt, sugar, and processed carbs while adding metformin 500 mg. twice a day, I have lost 55 pounds and my most recent blood sugar was 85. Metformin at this point in glucose management has very few side effects. Most people discuss diet or metformin in prediabetes, I am convinced that diet plus metformin makes much more sense. Metformin’s most common side effects are nausea and diarrhea which can be avoided if you take the medication properly— begin with 500 mg once a day, take it with food, take the extended release (ER) form, and increase the dose slowly. If you have diarrhea when you increase the dose, go back to the prior dose, and wait longer before increasing again. I treated many patients who “could not take metformin.” Most of them could take metformin if they followed these precautions. Metformin does not just lower the sugar; it has modest weight loss benefits and much broader impacts on protecting you beyond just lowering the glucose.

Prediabetes is another example of the consequences of the failure of American medicine to develop more effective chronic disease management. 84% of people with prediabetes don’t even know they have it. Obviously, they are not receiving the help they need to stay safe. Only a small minority of type 2 diabetic patients are achieving their goals for treatment. Consequently, far too many Americans are having heart attacks, strokes, and amputations and costs are far higher than they should be. I hope this information is useful to you, and if it is, please tell your friends.