March 19, 2013

Prevention or Delay of Type 2 Diabetes

The American Diabetes Association is very subtle in their discussion when it comes to prevention or delay of type 2 diabetes. Only where they need to, do they use the term prediabetes. Instead they prefer to use the term elevated risk for type 2 diabetes. To be on the same page requires some definition. “In 1997 and 2003, the Expert Committee on Diagnosis and Classification of Diabetes Mellitus recognized an intermediate group of individuals whose glucose levels do not meet criteria for diabetes, yet are higher than those considered normal.”

This is a reasonable definition, and a little further into the definition they say, Individuals with IFG (impaired fasting glucose) and/or IGT (impaired glucose testing) have been referred to as having prediabetes. The 2003 ADA Expert Committee report reduced the lower FPG (fasting plasma glucose) cut point to define IFG from 110 mg/dl (6.1 mmol/l) to 100 mg/dl (5.6 mmol/l). The World Health Organization (WHO) and many other diabetes organizations did not adopt this change in the definition of IFG.

People with IFG and IGT often have other cardiovascular risk factors, such as obesity, hypertension, and dyslipidemia. Assessing and treating these risk factors is an important aspect of reducing cardiometabolic risk. IFG and IGT are associated with obesity (especially abdominal or visceral obesity), dyslipidemia (a condition marked by abnormal concentrations of lipids or lipoproteins in the blood) with high triglycerides and/or low HDL cholesterol, and hypertension.

Individuals with an A1C of 5.7–6.4% should be counseled about their increased risk for diabetes as well as cardiovascular disease and counseled about effective strategies, such as weight loss and physical activity, to lower their risks. As with glucose measurements, the continuum of risk is curvilinear, so that as A1C rises, the risk of type 2 diabetes rises disproportionately. Interventions should be most intensive and follow-up should be particularly vigilant for those with A1C levels above 6.0%, who should be considered to be at very high risk. They emphasize that just as an individual with a fasting glucose of 98 mg/dl (5.4 mmol/l) may not be at negligible risk for diabetes, individuals with A1C levels below 5.7% may still be at risk, depending on level of A1C and presence of other risk factors, such as obesity and family history.

The experts have carefully tied diabetes to cardiovascular risks to promote the use of statins, though they don't say as much. It is a fact that the two are closely related and must be considered together, but with changes in lifestyle, both diabetes and cardiovascular risks may both be reduced. This means weight loss, exercise,stopping smoking, and other poor health habits.

Table 2 in this section describes the categories of increased risk for diabetes.
  1. IPG 100 mg/dl (5.6 mmol/l) to 125 mg/dl (6.9 mmol/l) [IFG]
  1. 2-h PG in the 75-g OGTT 140 mg/dl (7.8 mmol/l) to 199 mg/dl (11.0 mmol/l) [IGT]
  1. A1C 5.7–6.4%
For all three tests, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at higher ends of the range.

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