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Prediabetes: America's Growing Epidemic

Nurses encourage diet and exercise changes to prevent the spread of the disease

Approximately 86 million American adults or 1 person out of every 3 have prediabetes. 1 Prediabetes is characterized by higher than normal glucose readings that are not yet in the diabetic range. It is also referred to as impaired fasting glucose or impaired glucose tolerance. The lab values which constitute prediabetes are as follows: fasting blood glucose between 100-125 mg/dL, a hemoglobin A1c of 5.7%-6.4%, and/or a 2-hour glucose tolerance test of 140-199 mg/dL. If not treated prediabetes poses serious consequences, such as an increased risk of type II diabetes, cardiovascular disease and stroke, which can largely be prevented through diet and exercise. 1

The U.S. Preventive Services Task Force (USPSTF) released updated screening guidelines for prediabetes and type II diabetes in December 2015. "The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese." 2 These new recommended guidelines were updated from the 2008 USPSTF guidelines and are recommended in the asymptomatic, overweight, or obese patient presenting in the primary care setting. Patients who screen positive in the pre-diabetic range should be referred for intensive behavioral counseling and weight management, and should be encouraged to eat a more healthy diet and incorporate exercise into their lives to reduce the risk of developing  complications.

Lifestyle Interventions
Management of prediabetes with lifestyle intervention has proven to be effective according to two well-known studies: the Diabetic Prevention Program (DPP) in the United States and the Finnish Diabetes Prevention Study (DPS). These two studies both revealed a 58% relative risk reduction in the progression from prediabetes to type II diabetes during a mean intervention period of about 3 years. 3

As the existing evidence suggests, the importance of aggressive lifestyle intervention in the pre-diabetic population is paramount and can reverse or reduce the likelihood of developing type II diabetes and ultimately lowering the risk of cardiovascular disease and stroke. Managing diabetes is very costly and includes involvement from an interdisciplinary care team approach which includes primary care physicians, endocrinologists, dietitians, personal trainers, registered nurses, podiatrists, ophthalmologists and diabetes educators. Knowing the cost and detrimental effects of uncontrolled diabetes, pursing aggressive early intervention can better enhance the pre-diabetic's overall success rate of reversing or preventing the natural progression of the disease.

The DPP was a 27-center randomized clinical trial to determine whether lifestyle intervention or metformin therapy would prevent or delay the onset of diabetes in pre-diabetic patients who are at high risk for the disease. 4 The two major goals of the DPP lifestyle intervention were a minimum weight loss of 7% of current body weight and weigh maintenance, and a minimum of 150 minutes of physical activity per week with similar intensity to brisk walking. 4 The methods used to achieve these goals included a multitude of factors such as lifestyle coaches, supervised exercise sessions and extensive support. A tool called the Game Plan was developed from this study and should be implemented along with education of the primary care pre-diabetic patient to better enhance their journey of delaying or reversing the disease process.

Value of Physical Activity
The Finnish DPS was another randomized clinical trial that consisted of 522 middle-aged, overweight pre-diabetics who were randomized to either a usual care control group or an intensive lifestyle intervention group. 5 The main goals of the lifestyle intervention included: weight loss greater than or equal to 5% of current body weight, moderate intensity physical activity greater than or equal to 30 minutes per day, and dietary changes. 5 The lifestyle intervention group yielded positive results and significantly greater improvement in long-term dietary changes, physical activity and biochemical parameters than the control group, which suggests this intervention should be implemented in the primary care pre-diabetic population. 5 The risk of diabetes was reduced by 58% in the intensive lifestyle modification group compared with the control group. 5

Primary care providers can utilize diabetes prevention tools available to treat the pre-diabetic population, which has reached epidemic numbers. The Game Plan tool from the DPP study can help those pre-diabetics who may be struggling with aggressive lifestyle intervention. This tool is based on the lifestyle modification strategies from the DPP and can be found online at www.bsc.gwu.edu/dpp/manuals.htmlvdoc. It consists of disease specific information, prevention, weight loss goals and instruction, exercise goals and instruction, charts showing which patients are at-risk, a food and activity tracker, additional resources, and plenty of education on prediabetes. It provides the patient with a hands-on supplemental resource to enhance their process of preventing type II diabetes. It should not be used alone, but rather as a supplement to their aggressive diabetic management plan.

Pharmaceutical-Interventions
For those who fail to reach their goals with aggressive lifestyle intervention within 3 to 6 months pharmacotherapy may be appropriate. 6 The catch is that the FDA has not approved any medications for the use in those diagnosed with prediabetes. Many providers still prescribe some of the antihyperglycemics, especially in those with co-morbidities such as metabolic syndrome and cardiovascular disease. Metformin, a Biguanide, is a proven efficacious medication prescribed to those with type II diabetes and is the gold standard mono-therapeutic agent prescribed. According to the DPP, it was not as effective as aggressive lifestyle intervention, which had a 58% reduction in the progression of type II diabetes; although it yielded a 31% decrease relative to placebo. 6

The most important steps to take in the treatment of prediabetes are intensive diet and exercise. Achieving success is dependent upon the patient's willingness to remain focused, steadfast and compliant with a program that best works for them. Primary care providers have a responsibility to not only educate the pre-diabetic patient about the importance of diet and exercise, but to also serve as the coordinator and manager of their care. Initially starting with an aggressive diabetic management plan is paramount for success with appropriate referral to dibaetes educators, registered dieticians and personal trainers. The growing epidemic of prediabetes is a real problem for not only the United States, but entire world and we as providers must be vigilant in our care of the pre-diabetic patient to ensure optimal outcomes.

 Daniel P. McKnight is a nurse practitioner at the UPMC McKeesport Emergency Departmentworks at UPMC Hospital in Monroeville, Pa.

References

1.  Centers for Disease Control and Prevention (CDC). Prediabetes: Could it be you? http://www.cdc.gov/diabetes/pubs/statsreport14/prediabetes-infographic.pdf Accessed March 4, 2016.

2.  Siu AL. Screening for abnormal blood glucose and type 2 diabetes mellitus. Annals of Internal Medicine. 1 December 2015, 163(11):861-868. doi: 10.7326/M15-2345.

3. Lindstrom J, Ilanne-Parikka P, Peltonen M, et al. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet. 11 November 2006, 368(9548):1673-9.

4. National Institutes of Health (NIH). The Diabetes Prevention Program (DPP): Description of lifestyle intervention. Diabetes Care. 2002 December; 25(12): 2165-2171.

5.  Lindstrom J, Louheranta A, Mannelin M, et al. The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care. 2003 December; 26(12): 3230-6.

6. American Association of Clinical Endocrinologists (AACE). Management of prediabetes. http://outpatient.aace.com/prediabetes/management-of-prediabetes Accessed March 4, 2016.


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