Don't Wait to Treat Prediabetes

Prediabetes is defined as impaired glucose tolerance or impaired fasting glucose. Prediabetes is associated with an increased risk of cardiovascular disease and all-cause mortality. This is not something that doctors wish to recognize or discuss, as they are hesitant to give their patients concern about prediabetes.

The risk increased in people with a fasting glucose concentration as low as 100 mg/dl (5.55 mmol/L). A1C of 5.7%-6.5% (39-47 mmol/mol) or A1C of 6%-6.5% (42-47 mmol/mol) was associated with an increased risk of composite cardiovascular disease and coronary heart disease. Lifestyle modification is now the main management for people with prediabetes.

The question comes up after reviewing these studies as to whether we need to lower the cut-off point for defining prediabetes and that we might want to change the definition of prediabetes to a single number and not a range. Most doctors won't even consider this in a discussion of prediabetes.

The health risks and mortality associated with prediabetes seem to increase at the lower cut-off point for blood sugar levels recommended by some guidelines, finds a large study published in The BMJ. Prediabetes is a “pre-diagnosis” of diabetes — when a person’s blood glucose level is higher than normal, but not high enough to be considered diabetes. If left untreated, prediabetes can develop into type 2 diabetes. An estimated 79 million people in the U.S. are thought to be affected.

Doctors define prediabetes as impaired fasting glucose (higher than normal blood sugar levels after a period of fasting), impaired glucose tolerance (higher than normal blood sugar levels after eating), or raised hemoglobin levels. But the cut-off points vary across different guidelines and remain controversial.

For example, the World Health Organization (WHO) defines prediabetes as fasting plasma glucose of 110-125 mg/dl.(6.1-6.9 mmol/L), while the American Diabetes Association (ADA) guideline recommends a cut-off point of 100-125 mg/dl.(5.6-6.9 mmol/L.)

Results of studies on the association between prediabetes and the risk of cardiovascular disease and all-cause mortality are also inconsistent. Furthermore, whether raised hemoglobin A1C levels for defining prediabetes is useful for predicting future cardiovascular disease is unclear.

So, a team of researchers from the affiliated Hospital at Shunde, Southern Medical University in China analyzed the results of 53 studies involving over 1.6 million individuals to shed more light on associations between different definitions of prediabetes and the risk of cardiovascular disease, coronary heart disease, stroke, and all-cause mortality. They found that prediabetes, defined as impaired fasting glucose or impaired glucose tolerance, was associated with an increased risk of cardiovascular disease and all-cause mortality. The risk increased in people with a fasting glucose concentration as low as 100 mg/dl.(5.6 mmol/L) — the lower cut-off point according to ADA criteria.

Raised hemoglobin A1C levels were also associated with an increased risk of cardiovascular disease and coronary heart disease, but not with an increased risk of stroke and all-cause mortality.

The authors point to some study limitations that could have influenced their results, and say pulling observational evidence together in a systematic review and meta-analysis is a good way to consider all the evidence at once, “but we cannot make statements about cause and effect. We would need to look at experimental evidence for that.” However, they say their findings “strongly support” the lower cut-off point for impaired fasting glucose and raised hemoglobin A1C levels proposed by the ADA guideline.

They conclude that lifestyle change — eating a healthy balanced diet, keeping weight under control, and doing regular physical activity — is the most effective treatment at this time.

In conclusion, researchers found that prediabetes defined as impaired fasting glucose or impaired glucose tolerance is associated with an increased risk of composite cardiovascular events, coronary heart disease, stroke, and all-cause mortality. There was an increased risk in people with fasting plasma glucose as low as 100 mg/dl (5.6 mmol/L). Additionally, the risk of composite cardiovascular events and coronary heart disease increased in people with raised A1c, over 5.6%. These results support the lower cut-off point for impaired fasting glucose according to ADA criteria as well as the incorporation A1C in defining prediabetes. At present, lifestyle modification is the mainstay management for people with prediabetes. High risk subpopulations with prediabetes, especially combined with other cardiovascular risk factors, should be selected for controlled trials of pharmacological treatment because at this time we have no FDA-approved medications for prediabetes.

Chief investigator Yunzhao Hu, MD, PhD, professor in the department of cardiology at First People’s Hospital of Shunde in Foshan, China, added that, “The risk increased in people with fasting glucose levels as low as 100 mg/dl and with HbA1c of 5.7%…. So, we believe people with prediabetes should be followed up clinically and keep a healthy lifestyle. Plus, we need to develop models for risk stratification in people with prediabetes, and we need to find a drug treatment that can prevent CVDs in them.”

Guidelines for Prediabetes Screening not Followed

On November 9, Brenda called and asked if I had read about physicians not following the guidelines forprediabetes screening. I told her that I had not, but it was on the list to read. She said that Dr. Tom had called her and felt this would be a good topic for a group meeting.

I said I did not agree, but I would go along with the majority. I suggested she send out an email to our group and ask for their approval or reasons against it. I also suggested she send a similar email to Glen and Dr. Tom to discuss with their members to find out how many would attend. She agreed and I asked her if she could read Medscape articles. She answered no and I said I would send her a copy of one and instructions on how to join. I stated that I felt this could be more valuable for a group meeting, but I would not oppose what Dr. Tom had proposed.

The identification and treatment of prediabetes is one of the most effective ways to prevent patients from developing diabetes, but a new University of Florida study finds that only about half of family physicians report following national guidelines for screening patients for prediabetes.

Physicians also said that patient factors, such as sustaining a patient's motivation to make lifestyle changes, were significant barriers to diabetes prevention. The findings were published November 8 in the Journal of the American Board of Family Medicine.

More than a third of U.S. adults have prediabetes and most don't know it. Prediabetes, which is characterized by having blood glucose concentrations higher than normal, but not high enough for a diabetes diagnosis, can lead to vascular problems, kidney disease, and nerve and retinal damage. It is one of the greatest risk factors for the development of diabetes.

A previous study led by Arch G. Mainous III, Ph.D., chair of the department of health services research, management and policy in the UF College of Public Health and Health Professions, part of UF Health, found that very few patients who met the criteria for prediabetes were told by their doctors they had the condition. Less than one-quarter of those patients received drug or lifestyle modification treatment.

"For our next study we wanted to find out why the detection and treatment of prediabetes is so low when we know what the guidelines say about diagnosis and treatment and that many millions of Americans have this condition," said Mainous, the Florida Blue endowed chair of health administration. "We know from the literature that there are some different points of view on prediabetes. Some physicians think that a prediabetes diagnosis 'over medicalizes' patients, and some believe it is best to focus on providing general advice on healthy lifestyle."

The American Diabetes Association recommends that all adults who are overweight or obese or over the age of 45 should be screened for prediabetes. The U.S. Preventive Services Task Force recommends prediabetes screening for adults age 40 to 70 who are overweight or obese. Prediabetes treatment plans include drug therapy or intensive lifestyle modification.

The new UF study surveyed more than 1,200 family physicians working in an academic medical setting, asking them to rate the strength of the current evidence for prediabetes screening and treatment, the costs and benefits of formally diagnosing patients with prediabetes and the value in focusing on prediabetes as a way to prevent diabetes.

The researchers found that physicians who have a positive attitude toward prediabetes as a clinical condition were more likely to follow national guidelines for prediabetes screening and to offer treatment for their patients. Physicians who hold a negative attitude toward prediabetes were more likely to recommend to their patients general lifestyle changes that may reduce cardiovascular disease risk, but are not associated with lowering blood glucose levels.

"I'm hoping that we can change physician attitudes so that they follow and trust the screening and treatment guidelines, which are evidence-based, and view it as a worthwhile way to prevent diabetes," Mainous said.

Another key finding is that regardless of whether they hold a positive or negative attitude toward prediabetes, the majority of physicians surveyed indicated there are several patient barriers to diabetes prevention, including a patient's economic resources, sustaining patient motivation, a patient's ability to modify his or her lifestyle and time to educate patients.

"This suggests we need to provide new resources for physicians to support them in helping patients make lifestyle changes," Mainous said.

Physicians Passing on Treating Prediabetes

I am not sure the ADA actually said this. “According to the ADA, if A1C is between 5.7-6.4%, the patient is considered prediabetic and should be treated with lifestyle modifications and possibly metformin therapy.” But this is what the author of the article stated and I hope it is true, as a prediabetes diagnosis is a last call for patients to take action to possibly prevent a lifelong battle with diabetes.

As I explained in this blog, many doctors won't treat prediabetes in the hopes that they will soon have a patient with type 2 diabetes that they can treat. They use words like, “watch what you eat, as your blood sugar is elevated.” We know this is code for prediabetes and these doctors are licking their chops knowing they will soon have a captive patient to treat. I must state that not all doctors are this callus and do diagnosis prediabetes, but then fail to help the patient.

A new article published in Journal of the American Board of Family Medicine (JABFM) states that only 23% of prediabetes patients were diagnosed by their healthcare providers and started on appropriate therapy. Researchers looked at the data from the 2012 National Ambulatory Medical Care Survey, which included adults over 45 years of age with no diabetes and their A1C tested within the last 90 days. A1C results were categorized as normal, prediabetes, or diabetes and were broken down based on age, sex, race, payer type, body mass index, and prediabetes treatment.

A total of 518 visits were analyzed. The survey found that 54.6% of participants had a normal A1C, 33.6% had prediabetes, and 11.9% had diabetes. Only 23.0% of patients categorized as having prediabetes received treatment; the most common was counseling on lifestyle modifications. Rates of prediabetes were similar between men (36.5%) and women (40.0%). The most frequent primary diagnosis was hypertensive disease (16.3%). There were no noticeable differences in applied treatments based on HbA1c level range whether patients had an HbA1c level of 5.7% or 6.4%.

This proves the doctors don't have the best interests of their patients in mind and are afraid of diabetes and prediabetes. Why they won't prescribe metformin is unknown. This is a generic diabetes medication, very inexpensive, and many endocrinologists do prescribe it “off-label.” It is the safest diabetes drug available and while not FDA approved for prediabetes, it still needs to be prescribed.

Primary care physicians (PCPs) should play an active role in the lives of their patients who have prediabetes and diabetes. The increasing prevalence of diabetes is a major health problem and the American Diabetes Association recommends screening for prediabetes in all individuals over 44 years of age and children who are obese.

When patients do have elevated A1C, PCPs must intervene. By providing them counseling and medication therapy, and following up with them, PCPs can influence patients’ lives by delaying the onset of diabetes, or perhaps even preventing patients from transitioning to diabetes. Prevention is the most effective strategy to treat diabetes that we have so far, and can greatly improve the overall quality of life of an affected patient as well as help lower the total cost of healthcare for all of us.

In the last ten days, I have been in email correspondence with three individuals that actually asked for and received copies of their lab reports. All three had A1c's in the prediabetes range and asked what they should be doing. All stated that the doctor had made a statement like the one in the second paragraph above. I asked if they had insurance and explained that metformin would probably not be covered, but they should check this and testing supplies. If insurance would not cover any of this, they should investigate purchasing testing supplies from a pharmacy that was low cost and known for this. They needed to talk to their doctor about prescribing metformin ER (extended release) or even just metformin as it was a low cost generic.

Two of the individuals said their doctor would not prescribe metformin and I suggested they get a referral to an endocrinologist or lacking this, getting an appointment with one. Then they should talk to the endocrinologist about a prescription for metformin. They said they would and I have told all three that I would work with them on “eating to their meter” and learning what the meter readings were telling them.

This is one reason I promote obtaining your lab reports so that you will know what the results are and if there is need for concern and action on your part. I would suggest reading this article in Diabetes-in-Control.

Doctors Are Not Treating Prediabetes

Barry called me earlier this week, said he had something to talk to me about, and asked if I could come to his place. I said yes and headed out the door. When I arrived, I had expected Ben, but Allen and Tim were there also, plus another person we all were introduced to by Barry. Barry said his name for the group was Jay.

Barry then continued that Jay had a doctor appointment this morning and after the labs were discussed, Jay asked for a copy and the doctor had his nurse run a copy. Next, he wanted to prescribe a statin, a blood pressure medication, and another medicine that they talked about but he decided not to prescribe. Barry then said his plasma glucose was at 136 and his A1c was 6.4%. All that was said by the doctor was your sugar level is moving up and to watch what he ate. He said this is the main reason I called everyone here.

I asked Barry what he had discussed with Jay. Barry said he had looked at the lab results and from the lab results and asking Jay what his blood pressure was, he could see that he needed the blood pressure medication. He said that he wanted the rest of us to look at the cholesterol numbers, as he didn't think a statin is warranted. Jay handed the report to Allen and Allen read it to the rest of us. HDL 58, LDL 84, Triglycerides 70 and a few ratios. All agreed that statins should not be needed.

I added that the reason for the statin prescription is obvious – his A1c is 6.4% and this tells most doctors to prescribe a statin. Tim said he agreed with me and that is the reason for not diagnosing prediabetes and prescribing metformin or insulin to help the pancreas heal and possibly delay or prevent diabetes.

Ben spoke then and said he agreed and said that we should get him to a doctor that will diagnose and is not afraid of prescribing. Allen said he was on the fence, but with the A1c, he could understand and would support us. Jay started asking questions then and said he did not want to go to another doctor. Barry then asked if he wanted to know about prediabetes. Jay said if it was serious, the doctor would have said something.

Tim and I looked at each other and Tim said to Jay, that it was his choice, but when he actually has diabetes, he cannot say he did not have a warning, unlike the rest of us that did not know until diagnosis. With his plasma glucose reading and the A1c, he should know that he is moving toward type 2 diabetes rather rapidly.

Jay asked Barry if this was true. Barry said yes, and if you continue to ignore it, you will soon have diabetes. Barry then added that it may be too late with an A1c of 6.4%. Ben added that the doctor sees this and knows he will soon have a patient with type 2 diabetes that he will be able to treat. Allen said the comment he made “your sugar level is moving up and to watch what he ate,” is what we understand now as code for prediabetes.

I said that is the reason most doctors will not diagnosis prediabetes is because they know that they will soon have a patient to treat and possibly more regularly if they don't manage it properly. Doctors in general, believe diabetes is progressive and people will develop some of the complications and they will be able to treat many of the complications.

Jay asked what complications? Barry started with blindness; kidney failure, meaning dialysis; heart disease; nerve damage, meaning pain for many people; and possible organ failure. I could see Jay looking very worried. I said this does not have to be this way, but it does require action by you to change your way of eating, exercise regularly, if able, and test regularly. I said some people go through stages – anger or shock, denial, and finally acceptance before they take action.

Tim said if you will let us get you to an endocrinologist that knows diabetes, he can give you medication(s) that will help manage your blood glucose problem and possibly prevent diabetes from developing. Your A1c does indicate a serious problem with blood glucose and does need to be treated now. Jay finally admitted he was concerned and asked Barry who he would recommend. Barry said he would take him if Allen would go with him once he had an appointment. Allen said he had the phone number, started the call, and then handed he phone to Jay and we could hear Jay giving the receptionist his information. Jay finished and told Barry his appointment was for April 29 at 2:20 PM.

Tim asked Jay if he had a computer and he said he did. Barry said he would give Jay some of my blogs, some by David Mendosa, and other areas to read. Tim thanked him and we excused ourselves and left.

I forgot to say anything about the public service advertising about predicates, as this is an on target promotion and deserves our attention. I have now seen four of their ads and the last two were not over the top and were on target to wake people up about prediabetes.

Prediabetes PSA Promoted by Major Medical Groups

At first, I had passed on this topic, but after a discussion with Scott Johnson about this and his promotion on his blog, I feel that I need to write about the public service advertising (PSA) about prediabetes.

Another type 2 blogger has also blogged about this, but was very negative in her thoughts. She may be correct in her thinking, but I feel that the campaign is on target and I have seen two of the ads. Yes, they are over the top in a way, but with all the noise of political ads, I feel that the promotion will do more good than harm. It needs to be shocking and use language that will capture people's attention.

In discussing this with Scott, he made some excellent observations and I have his permission to use them. Scott says: (and I agree)

“- Something with this much attitude is certain to upset some. Totally expected.

- I'm trying to keep in mind the intended audience for these messages. It's not us. These are TV commercials designed to grab people's attention in the midst of all the other media noise. A tough job.

- With that in mind, do we really think a piece about diabetes in the tone we're used to seeing would do anything? I don't.

- If these can catch even a few people among the many who will ignore them, it's helping more than hurting.”

In this year of political ads and their constant noise, I do hate to have the TV and even the radio on during the ads. This is why I don't feel that the PSA's are that offensive.

Losing weight and being healthier are at the top of most everyone’s New Year’s resolutions. But, despite the best intentions, work, kids, and social events often push lifestyle changes to the bottom of the list. While many are familiar with type 2 diabetes, fewer are aware of prediabetes, a serious health condition that affects 86 million Americans (more than 1 in 3) and often leads to type 2 diabetes. People with prediabetes have higher than normal blood glucose (sugar) levels, but not high enough yet to be diagnosed with type 2 diabetes.

To raise awareness and help people with prediabetes know where they stand and how to prevent type 2 diabetes, the American Diabetes Association (ADA), the American Medical Association (AMA), and the Centers for Disease Control and Prevention (CDC) have partnered with the Ad Council to launch the first national public service advertising (PSA) campaign about prediabetes. The PSA campaign, featuring first-of-its-kind communications techniques, was developed pro bono by Ogilvy & Mather New York for the Ad Council.

Nearly 90 percent of people with prediabetes don’t know they have it and aren’t aware of the long-term risks to their health, including type 2 diabetes, heart attack, and stroke. Current trends suggest that, if not treated, 15 to 30 percent of people with prediabetes will develop type 2 diabetes within five years. The good news is that prediabetes often can be reversed through weight loss, diet changes and increased physical activity. Diagnosis is the key.

Have Prediabetes, Steps to Take Now

Receiving a diagnosis of prediabetes can be a good thing. Still many people do not use this wake-up call and let it progress to type 2 diabetes. I was not one of the lucky ones as I was diagnosed with type 2 diabetes shortly after the ADA had the “experts” declare the range of 100 to 125 mg/dl as prediabetes in 2003.

Receiving a diagnosis of prediabetes should be a serious wake-up call, but most doctors refuse to give this to patients. The doctors still use the terms “watch what you eat as your blood sugar is creeping up,” or “your blood sugar is elevated.” Other doctors still use the older term “borderline diabetic”, or that you have a “touch of sugar.” Most times you will not even be told anything if your blood glucose levels are less than 115 to 120 mg/dl.

The above is the reason to always ask for a copy of all test results. This is how you can check what your doctor tells you and you will know if you have prediabetes.

Knowing that you have prediabetes does not mean that you will definitely develop diabetes. You often still have time to prevent the development of type 2 diabetes. You and you alone have an opportunity to initiate changes and possibly prevent the progression to type 2 diabetes. Consider making these seven changes in your daily habits.

1. Move More Becoming more active is one of the best things you can do to make diabetes less likely. If it's been a while since you exercised, start by building more activity into your routine by taking the stairs or doing some stretching during TV commercials. Physical activity is an essential part of the treatment plan for prediabetes, because it lowers blood glucose levels and decreases body fat. Ideally, you should exercise at least 30 minutes a day, five days a week. Let your doctor know about your exercise plans and it is important to ask if you have any limitations.

2. Lower Your Weight If you're overweight, you might not have to lose as much as you think to make a difference. In one study, people who had prediabetes and lost 5% to 7% of their body weight (just 10-14 pounds in someone who weights 200 pounds) cut their chances of getting diabetes by 58%.

3. See Your Doctor More Often See your doctor every three to six months or find a different doctor if he has refused to recognized prediabetes. If you're doing well, you can get positive reinforcement from your doctor. If it's not going so well, your doctor can help you get back on track. Patients like some tangible evidence of success or failure.

4. Eat Better

• Load up on vegetables, especially the less-starchy kinds such as spinach, broccoli, and green beans. Aim for at least three servings a day.
• Add more high-fiber foods into your day.
• Enjoy fruits in moderation - 1 to 3 servings per day.

Also, swap out high-calorie foods. Drink whole milk, diet soda rather than regular soda. Choose fatty versions of cheese and yogurt. Choose fresh fruit and peanut butter.

5. Make Sleep a Priority

Not getting enough sleep regularly makes losing weight harder. A sleep shortfall also makes it harder for your body to use insulin effectively and may make type 2 diabetes more likely. Set good sleep habits. Attempt to go to bed and wake up at the same time every day. Relax before you turn out the lights. Don't watch TV or use your computer or smartphone when you're trying to fall asleep. Avoid caffeine after lunch if you have trouble sleeping.

6. Get Support Losing weight, eating a healthy diet, and exercising regularly is easier if you have people helping you out, holding you accountable, and cheering you on. Consider joining a group where you can pursue a healthier lifestyle in the company of others with similar goals.

7. Choose and Commit

Having the right mind-set can help. This means having a positive attitude above all else. Accept that you won’t do things perfectly every day, but pledge to do your best most of the time. Make a conscious choice to be consistent with everyday activities that are in the best interest of your health. Tell yourself, ‘I’m going to give it my best. I’m going to make small changes over time.’ These changes will add up.

Treat Prediabetes as Type 2 Diabetes

Yes, this should be done. First, some definitions – Prediabetes = blood glucose levels of 100 mg/dl to 125 mg/dl and diabetes is considered anything above 125 mg/dl. As I stated in my previous blog, we should treat prediabetes as diabetes, no more and no less. It isn't even humorous that the majority of doctors ignore prediabetes completely.

You may hear doctors comment that, “watch what you eat as your blood sugar is creeping up,” or “your blood sugar is elevated.” Other doctors still use the older term “borderline diabetic”, or that you have a “touch of sugar.” Most times you will not even be told anything if your blood glucose levels are less than 115 to 120 mg/dl. We recently had a friend of Allen's comment that his blood glucose was 103 mg/dl and his doctor did not say anything. Allen asked him how he knew even this and his friend answered he always asks for a copy of his tests. His blood glucose test before the last one had been 98 mg/dl.

Allen said his friend had asked him if he did not have prediabetes and Allen agreed that he did. Allen said they had talked the rest of the evening about what he could do to gain control of his prediabetes. Allen covered the food plan that most of us use and developing an exercise plan. Allen said he had a substantial exercise regimen in place so they spent most of the time on a food plan. Tim suggest that he tell his friend that if he went above 115 mg/dl that he ask for a minimum dose of 500 mg (off-label) to be taken with his evening meal. Several other members that were gathered with us agreed.

I explained that it really did not matter, as any reading over 99 mg/dl meant that his pancreas was having problems and should receive assistance whether with exercise, a low carb, high fat (LCHF) food plan, or a medication. Tim agreed and added that is best for slowing the decline or healing of the pancreas. The younger a person, the best chance of healing and preventing the onset of type 2 diabetes. In an elder person, healing may not work, but often can delay the onset of type 2 diabetes.

Barry asked if his friend was testing and Allen said they had talked about this, but not made any decisions. Tim said that we should always suggest that they obtain a meter and test strips they can afford and if they have problems with this, they should consider a meter and test strips that they can obtain at Walmart. I agreed with Tim and said that once they have a meter and test strips, someone from this group should spend time explaining the best method of testing and what the test results mean, by teaching Self-Monitoring of Blood Glucose (SMBG). Then we should explain goal setting and what might be reasonable goals for them.

Brenda said that we should suggest various goals. She asked for anyone that disagreed to say something and we would discuss each point. Since we are dealing with prediabetes, fasting should be from 65 to 100 mg/dl and not higher. She said that fasting readings of higher than 100 indicates the need for meal plan concern and possible metformin. Postprandial should always be below 140 mg/dl and preferably not higher than 120 mg/dl. Readings higher that 140 mg/dl indicates meal plan problems and need for metformin possibly two times per day. She said I know this disagrees with the metformin recommended before, but until they bring the number of carbohydrates down and increase the fat consumption, metformin may be necessary.

This generated some discussion and most wanted the postprandial set at 120 or 125 mg/dl. We agreed on 140 to begin until they had a good meal plan (LCHF) and then bring it down to 120 mg/dl. Some felt that fasting should be 65 to 90 mg/dl, but most were comfortable with the 65 to 100 mg/dl. Tim also felt that anyone with fasting numbers 100 or above should ask for an HbA1c test and everyone agreed. We all agreed that even with the term prediabetes, we should consider it as the earliest stage of type 2 diabetes.

Treat Prediabetes as Diabetes

What can we as people with type 2 diabetes do to encourage our doctors and other professionals to help people with prediabetes? This is a difficult question and David Mendosa tackles prediabetes from a different perspective that is interesting to read.

David says, “If you have prediabetes, taking the diabetes drug metformin might stop you from getting diabetes and could also help you in other ways. But persuading your doctor to prescribe it could be a challenge.” Yes, many doctors will not prescribe metformin “off label” and probably because they do not feel this is the correct thing to do.

Lifestyle intervention is not working because most doctors and certified diabetes educators refuse to work with people with prediabetes. Without education and reinforcement, most people will fail here because of the term prediabetes and the lack of seriousness by doctors and CDEs.

The biggest factor hurting people with prediabetes is the American Diabetes Association. The ADA only gives prediabetes a casual mention and even ignores many people with type 2 diabetes when Dr. Robert Ratner, chief scientific and medical officer for the ADA that says, “Many people with type 2 diabetes who are on medications don't need to do home glucose monitoring at all," in talking about oral medications.

It is this attitude that discourages doctors and especially patients when they know that people inside the ADA are not on their side and working to make management of diabetes work for them. Dr. Ratner wants people with type 2 diabetes to manage diabetes in the dark and make diabetes progressive.

Fortunately, many people are learning to buy the testing supplies on their own, are reading on their own to manage prediabetes and type 2 diabetes, and are ignoring the ADA. I have many people that ask me why I cover some of the ADA guidelines when they don't care about people with prediabetes and diabetes. I have to tell them that we still need to be aware of what they are saying and if there is any hope for change. The ADA has changed some in recent years, but still done very little for helping people with prediabetes, which is a group of people they created in 2003 with their experts.

David does cover some of the known side effects of metformin and gives some of the proper warnings. You should take the time to read his blog.

Being Screened for Prediabetes and Diabetes

One-third of adults with diabetes don't know they have it, according to the National Institutes of Health.

This is scary! The blog at the Mayo Clinic about is taking a pro-active point of view and calling for people meeting the following criteria to be tested for diabetes or prediabetes.

The NIH says that you are at greater risk of developing prediabetes and type 2 diabetes if you:

• Are age 45 or older
• Have a family history of diabetes
• Are overweight
• Have an inactive lifestyle
• Are members of a high-risk ethnic population (e.g., African American, Hispanic/Latino American, American Indian and Alaska native, Asian American, Pacific Islander)
• Have high blood pressure: 140/90 mm/Hg or higher
• Have HDL cholesterol less than 35 mg/dl or a triglyceride level 250 mg/dl or higher
• Have had diabetes that developed during pregnancy (gestational diabetes) or have given birth to a baby weighing more than 9 pounds
• Have polycystic ovary syndrome, a metabolic disorder that affects the female reproductive system
• Have dark, thickened skin around neck or armpits
• Have a history of disease of the blood vessels to the heart, brain, or legs

If you're age 45 or older, ask your healthcare provider about testing for diabetes or prediabetes. If you are younger than 45 and overweight, and have another risk factor, you should also ask about testing.

If you have prediabetes you can often prevent or delay diabetes if you lose a modest amount of weight by cutting calories or increasing physical activity. If you're overweight and lose just 5-7 percent of your body weight, you can lower diabetes onset by 58 percent. That is why early detection is so important.

Why doctors will not test more people is a puzzle, but many doctors are trying to keep costs down and therefore do little diabetes testing until forced into it. They seem to care less about the health of their patients until there is an actual problem and then many will dismiss diabetes by saying, “Watch what you eat as your blood sugar is a little high.”

If your doctor says this, then it is time to ask for a copy of the test results and really take a look at the tests. If your blood glucose level is above 125 mg/dl, then chances are good that you have diabetes or prediabetes and should be having a serious talk with your doctor. If the doctor just repeats the above statement, then it is time to look for another doctor – seriously.

A.J and I are having a discussion with an acquaintance of ours that is overweight and the last time he went to the doctor A.J did ask him to obtain a copy of his tests. When he showed us the sheet, A.J told him he was probably a person with diabetes and then A.J asked if I agreed. When I saw the results, I said he is even higher than you (A.J) were when you were diagnosed – 209 mg/dl.

The fellow said it was not fasting and his wife had fixed his favorite breakfast of pancakes before he went to the doctor. I asked how long from breakfast until they drew blood and he answered about three hours. I answered that if he did not have diabetes, his reading would have been at or below 100 mg/dl at two hours. Because his reading was still that high at three hours, he could count on having diabetes. A.J said he agreed with me and asked him which doctor he wanted to see and gave him three names.

The fellow said not at this time and he would need more proof than one test. A.J started to encourage him and I shook my head. When the fellow moved off, A,J asked why I had discouraged him. I said you did not see the recording device he had on record and he will probably replay it several times and then call one of the three doctors you gave him. I said I had watched his body language change drastically when I said if he did not have diabetes, his blood glucose level would be at or below 100 at two hours. He was alarmed and it showed. A.J said he would not push and see what happened. With that we went out separate ways.

Doctors Ignore Guidelines for Prediabetes Patients

Many of the diabetes news sources are carrying this news item. The titles vary by what each source wants to emphasize. Basically, the consensus is disparaging about doctors that are under using metformin to treat prediabetes. Considering that the drug is generic and cheap, I can agree that this is an inexpensive therapy to help manage and possibly prevent the full onset of type 2 diabetes.

Before I continue, I will make some observations. First, I am not surprised at the lack of prescriptions for metformin because many doctors are not screening for prediabetes. Second, many doctors believe prediabetes and diabetes are a lifestyle disease and want patients to suffer and will not prescribe any medications until full diabetes is present and sometimes even then will delay medications. These doctors want to see improvement in weight and other lifestyle changes that prove the patient will follow a medication regimen. Many patients often surprise these doctors by making the lifestyle changes and not needing the medications the doctors were planning to make them take because the doctors believe that prediabetes and diabetes are progressive and people will not be able to manage their prediabetes or diabetes.

Metformin was prescribed for only 3.7% of patients with prediabetes, even though it can help prevent the onset of type 2 diabetes, according to a new retrospective cohort analysis. Lead author Tannaz Moin, MD, from the David Geffen School of Medicine at University of California, Los Angeles, says, “We were surprised to see just how low the [prescription] rates were, particularly among the highest-risk individuals, where evidence for metformin use is strongest."

"Despite inclusion in national guidelines for more than 6 years and proven long-term tolerability, safety, and cost-effectiveness, the prescription of metformin in the real-world clinical approach to diabetes prevention remains unclear," Dr Moin and colleagues write.

Their findings are published in the April 21 issue of the Annals of Internal Medicine.

Among those with a BMI equal to or greater than 35 kg/m2 (n= 391) or gestational diabetes (n = 121) the prevalence of metformin prescription was 7.8%. This is "the group for which the ADA guideline places the most emphasis on treating prediabetes with metformin," the authors write.

In their study, Dr Moin and colleagues analyzed data from a national sample of 17,352 adults aged 19 to 58 years with prediabetes between 2010 and 2012 who were insured for 3 continuous years to determine the percentage who were prescribed metformin.

In 2008, the American Diabetes Association (ADA) updated its "Standards for Medical Care in Diabetes" guidelines to include metformin use in patients aged less than 60 years who are at very high risk [of diabetes], are very obese (body mass index [BMI] greater than 35 kg/m2), or have a history of gestational diabetes.

The guidelines also say clinicians can consider metformin in those with impaired glucose tolerance, impaired fasting glucose, or an HbA1c of 5.7% to 6.4%.

Again, this study is interesting and would be more valuable if doctors were taking prediabetes seriously and screening for it.

Two other articles can be read. The first is from Science Daily, titled “Drug that can prevent onset of diabetes is rarely used.” The second is from Diabetes-in-Control and is titled “Metformin Reported in Use with Only 3.7% of Those with Prediabetes.”

Learn Prediabetes Is Not Diabetes

Since 2003, when the American Diabetes Association (ADA) convened a group of “experts” to declare the blood glucose levels between 100 and 125 mg/dl (3.9 to 6.9 mmol/L) as prediabetes, all people were aware of was that diabetes started at 126 mg/dl (7.0 mmol/L).  This classification applies only to type 2 diabetes.

Since then the ADA has done little to encourage doctors to screen for prediabetes.  A few doctors have been screening for prediabetes and doing an excellent job at this, but the bulk of people with prediabetes are still unaware they even have this.  The ADA, for all their “expert” knowledge, has done little in the way of education or helping the people that might have prediabetes become aware of what might happen if they do nothing to prevent the onset of full type 2 diabetes.  

Receiving a diagnosis of prediabetes is a serious wake-up event.  It does not necessarily mean that type 2 diabetes is a foregone conclusion.  There are changes that you can make to slow the progression to diabetes and for some people to prevent diabetes.  The following are some suggestions to consider:

Develop an exercise regimen you enjoy.  Doing this is one of the best things you can do to make diabetes less likely.  If it has been a while since you exercised or you are medically able, start by building more activity into your routine by taking the stairs or doing some stretching during TV commercials.  Physical activity is an essential part of the treatment plan for prediabetes, because it lowers blood glucose levels and decreases body fat.  Check with your doctor to see if you have limitations.

Lower your weight if this is needed.  If you're overweight, you might not have to lose as much as you think to make a difference.  In one study, people who had prediabetes and lost 5% to 7% of their body weight (just 10-14 pounds in someone who weights 200 pounds) cut their chances of getting diabetes by 58%.

See your doctor more often if possible.  It is recommended to see your doctor every three to six months.  If you're doing well, you may get positive reinforcement from your doctor.  If it's not going so well, your doctor can help you get back on track.  If you are like me, you will appreciate words of encouragement, and even words needed to put you back on the right path.

Develop a good food plan that your meter approves.  Load up on vegetables, especially the less-starchy kinds such as spinach, broccoli, carrots, and green beans.  Aim for at least three servings a day.  Add more high-fiber foods into your day.  Enjoy fruits in moderation - 1 to 3 servings per day. Eliminate whole-grain foods as much as possible and do eliminate processed grains.  In general, eliminate white rice from your food plan.

Also, swap out high-calorie drinks.  Drink whole milk rather than skim milk and diet soda rather than regular soda.  Choose cheese, yogurt, and low carb salad dressings. Choose fresh fruit when it is available and not fruit juice.

Make sleep a priority and sleep the suggested hours when possible.  Not getting enough sleep regularly makes losing weight more difficult.  A sleep shortfall also makes it harder for your body to use insulin effectively and may make prediabetes and diabetes more difficult to manage.  Set good sleep habits.  Go to bed and wake up at the same time every day. Relax before you turn out the lights.  Don't watch TV or use your computer or smartphone when you're trying to fall asleep.  Avoid caffeine after lunch if you have trouble sleeping.

Get support and ask for help when needed.  Losing weight, eating a healthy diet, and exercising regularly is easier if you have people helping you out, holding you accountable, and cheering you on.  Consider joining a group where you can pursue a healthier lifestyle in the company of others with similar goals.  The right diabetes educator and nutritionist may also help you learn about what you need to do to prevent your prediabetes from becoming diabetes.  Sometimes this will be a doctor, a nurse, or just a friend.

Choose and commit to the task of managing your diabetes.  Having the right mind-set and a positive attitude can help.  Learn to accept that you won’t do things perfectly every day, but pledge to do your best most of the time.  Make a conscious choice to be consistent as possible with everyday activities that are in the best interest of your health.  Learn to tell yourself, I’m going to give it my best.  I’m going to make small changes over time that will become good habits.  These changes will add up over time and help you manage your prediabetes or diabetes if it progresses that far.

Additional Information on USPSTF Pronouncement

On October 21, I received an email from the ADA promoting the US Preventive Services Task Force (USPSTF) pronouncement. While I can agree with much of what they are advocating, I am totally turned off when they label USPSTF as alphabet soup because the acronym is six letters long. To me this means that the ADA is belittling the USPSTF and does not show respect.

Then they use scare tactics by listing the serious complications that diabetes may cause supposedly to show how serious diabetes can be. If the ADA was actually calling for action and supporting the pronouncement of the USPSTF, you would think they could choose a more positive introduction. Diabetes receives enough bad publicity without the ADA adding to this.

Why they use the term Diabetes Advocates to apply to themselves is a puzzle. The email author then says, “This month our years of hard work paid off and the USPSTF recommended – for the first time – that Americans with key risk factors should be tested for diabetes. Studies show that currently more than half of people with undiagnosed diabetes are not tested because they do not meet the current diabetes screening guidelines. Now this will change!”

The author also says this matters because doctors around the country follow USPSTF recommendations. Then the email author says this is vital testing will be completely paid for by a patient's health insurance. Now this is where the two doctors I have been corresponding with have expressed caution. They both agreed that most private insurance companies may pay for the screenings, but will they pay for the follow-up appointments if the tests are positive. Medicare is the other concern as they have been in the habit of not paying.

The doctors do have a large concern about those that fall into the prediabetes range. Without the ADA making this an official classification, they feel this will still be an area that will not be covered, even with a prediabetes diagnosis.

The author of the ADA newsletter declared that the change is critical citing the estimated annual economic cost of undiagnosed diabetes is a staggering $18 billion. With this change, the 10 million Americans with undiagnosed diabetes and the 86 million with prediabetes will have a fighting chance to take action before the devastating complications of diabetes take hold, saving both lives and dollars.

The one thing that makes me hopeful – will the ADA do something about renaming prediabetes and make it an official diabetes designation? One can only hope.

An Argument Against the Prediabetes Classification

At least this is not a study, but an analysis by “experts.” They are talking about the two parts – the medicine and the politics of prediabetes. The article is part of a series in the British Medical Journal on over diagnosis. They say that the risks and harms to patients will depend in expanding disease definitions. They began their analysis by reminding the reader that prediabetes is a heterogeneous concept or a concept composed of parts of different kinds, having widely dissimilar elements or constituents:

“Concept one” - The original category of intermediate hyperglycemia was termed "impaired glucose tolerance" and was based on the oral glucose tolerance test. Only since 1997 was an intermediate category of "impaired fasting glucose" created, “concept two” with revision in 2003 to expand the range of qualifying values. “Concept three” Because A1c was not used for diagnostic testing until 2010; it is only recently that a nameless intermediate category based on A1c was designated. Unfortunately, the overlap of these three definitions is far from perfect, so the starting point for the discussion is already confused. This is the interpretation of the experts.

They declare there is a limited value of prediabetes. They said the importance was whether a diagnosis of prediabetes guarantees a future diagnosis of diabetes. They declare that no matter how prediabetes is defined, the answer is “no” - less than one-half of all such people will develop diabetes within 10 years. The two authors say that clinical trials from around the world have demonstrated that diabetes risk among high-risk individuals can indeed be reduced, but Yudkin and Montori argue that diabetes onset was merely delayed by 2-4 years, at high cost and only among a subset of the intervention groups.

“The following quote summarizes their position: "The US Diabetes Prevention Program results imply that you can give an at-risk person with pre-diabetes a 100% chance of using metformin with the goal of reducing by 31% their risk of developing a condition that might require them to use metformin." Yudkin and Montori conclude that it is critically important to address the epidemic of obesity and diabetes. However, they assert that available resources should be used to change the root causes of the epidemic rather than to medicalize otherwise healthy patients with prediabetes.”

Then they switch to a study published in Diabetes Care about the risk of cardiovascular disease (CVD) in people with prediabetes. “The Diabetes Prevention Program Outcomes Study (DPPOS) is the follow-up to a randomized clinical trial of individuals who had prediabetes. Of the 2775 participants in DPPOS, 1509 (54%) had achieved normal glucose regulation (NGR) at least once during the DPP, whereas 496 (18%) remained with prediabetes and 770 (28%) developed diabetes. The investigators also compared individual CVD risk factors, including cholesterol, smoking status, blood pressure, and diabetes status, all assessed annually.”

What bothers me is that 54 percent of people with prediabetes do have problems with high blood pressure and need medications and 34 percent used statins and these “experts” say we should not be concerned with prediabetes. Yes, this does mean that possibly some may be medicated that should not be, but if they could focus on those with the greatest risk factors then some would be missed, but many would be helped.

Maybe the new method of determining diabetes need to be put in place as this would be a great diagnostic tool and could more accurately tell which people with prediabetes were at risk. Read my blog here about the possible new test.

It is my opinion that these “experts” should support testing people for prediabetes and using every test possible to find those at risk for developing type 2 diabetes.

Change May Be Coming for Prediabetes

Yes, it may still be a few years in the future, but if researchers continue to make their voices heard, the American Diabetes Association (ADA) may feel the pressure. At present, the ADA has not given much attention to prediabetes and the term has caused most doctors to ignore prediabetes since it has no real official status. Even the medical insurance industry gives it no support.

I will quote the lead-in to the Science Daily article as it expresses what needs to be said about prediabetes.

“Treating patients with prediabetes as if they had diabetes could help prevent or delay the most severe complications associated with this chronic disease, experts say. The researchers say that by not devising a treatment strategy for people with prediabetes, doctors run the risk of creating a pool of future patients with high blood sugar who then become more likely to develop serious complications, such as kidney disease, blindness, amputations, and heart disease.”

It seems that most doctors want to create a pool of future patients with high blood glucose levels. This may be the reason for the ADA not classifying prediabetes as diabetes and making it an official part of diabetes classification types. The term needs to go and be renamed, as outlined in my previous blog, Suggestions for ADA, but with more researchers recognizing the need, something may be done in the future and hopefully the near future.

According to the study authors, evidence comes from clinical trials where lifestyle change and/or glucose-lowering medications decreased the progression from prediabetes to type 2 diabetes. After leaving the interventions, the development of diabetes remained less in people who changed their lifestyle and/or took medications compared to the control group of prediabetes patients who did not have interventions.

The study authors say, “First, adults should be screened systematically to find prediabetes and early type 2 diabetes. And second, patients who are likely to benefit from treatment should have management aimed to keep their blood glucose levels as close to normal as possible.”

Lead author of the editorial, Lawrence Phillips, MD, from Emory University said, "Diabetes is generally diagnosed and first treated about ten years later than it could be. We waste this critical opportunity to slow disease progression and the development of complications. There is a strong, new argument that by combining screening to find prediabetes and early diabetes, along with management aimed to keep glucose levels as close to normal as possible, we can change the natural history of the disease and improve the lives of our patients."

Note: I will have another blog about the other side of diabetes which is not favorable for anything but more speculation. Hopefully, it will be ready next week.

Is It Possible?

Every now and then I get to wondering about the different types of diabetes and if there is more to the diagnosis than the medical community is acknowledging. With the new guidelines from the American Diabetes Association which can be read here (and I urge you to take time to read this), I often read this more carefully than any other provision or discussion in the guidelines. Then I start to look for what they may not be telling us. In any of the discussions, they seem to like to paraphrase some areas by saying that there is much to be determined at the clinical level.

The definition by its very nature leaves many questions, “Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of different organs, especially the eyes, kidneys, nerves, heart, and blood vessels.”

I am using only the first part of the long definition because I think this is where some defining needs to be done. Yes, I agree that diabetes is a metabolic disease and maybe a group. Why the term hyperglycemia is not defined as being a certain measurable amount or number leaves me wondering what they are looking for in not defining this. Certainly they have a number in mind. Then they use chronic hyperglycemia to define what may happen to certain organs. I can understand why some organs are missing from the list because of the lack of conclusive studies for hearing and cognitive decline (brain). I do question why they are not given any mention and a statement of lack of conclusive evidence. That could then spark studies to prove that. I suspect they are not mentioned to avoid these studies from taking place, but why?

The classification for the last several years has gotten more restricted and only includes four classifications. Table one below shows the four classes.

Table 1 Etiologic classification of diabetes mellitus:

1. Type 1 diabetes (β-cell destruction, usually leading to absolute insulin deficiency) 1. Immune mediated 2. Idiopathic 2. Type 2 diabetes (may range from predominantly insulin resistance with relative insulin deficiency to a predominantly secretory defect with insulin resistance) 3. Other specific types 1. Genetic defects of β-cell function 1. MODY 3 (Chromosome 12, HNF-1α) 2. MODY 1 (Chromosome 20, HNF-4α) 3. MODY 2 (Chromosome 7, glucokinase) 4. Other very rare forms of MODY (e.g., MODY 4: Chromosome 13, insulin promoter factor-1; MODY 6: Chromosome 2, NeuroD1; MODY 7: Chromosome 9, carboxyl ester lipase) 5. Transient neonatal diabetes (most commonly ZAC/HYAMI imprinting defect on 6q24) 6. Permanent neonatal diabetes (most commonly KCNJ11 gene encoding Kir6.2 subunit of β-cell KATP channel) 7. Mitochondrial DNA 8. Others 2. Genetic defects in insulin action 1. Type A insulin resistance 2. Leprechaunism 3. Rabson-Mendenhall syndrome 4. Lipoatrophic diabetes 5. Others 3. Diseases of the exocrine pancreas 1. Pancreatitis 2. Trauma/pancreatectomy 3. Neoplasia 4. Cystic fibrosis 5. Hemochromatosis 6. Fibrocalculous pancreatopathy 7. Others 4. Endocrinopathies 1. Acromegaly 2. Cushing's syndrome 3. Glucagonoma 4. Pheochromocytoma 5. Hyperthyroidism 6. Somatostatinoma 7. Aldosteronoma 8. Others 5. Drug or chemical induced 1. Vacor 2. Pentamidine 3. Nicotinic acid 4. Glucocorticoids 5. Thyroid hormone 6. Diazoxide 7. β-Adrenergic agonists 8. Thiazides 9. Dilantin 10. γ-Interferon 11. Others 6. Infections 1. Congenital rubella 2. Cytomegalovirus 3. Others 7. Uncommon forms of immune-mediated diabetes 1. “Stiff-man” syndrome 2. Anti-insulin receptor antibodies 3. Others 8. Other genetic syndromes sometimes associated with diabetes 1. Down syndrome 2. Klinefelter syndrome 3. Turner syndrome 4. Wolfram syndrome 5. Friedreich ataxia 6. Huntington chorea 7. Laurence-Moon-Biedl syndrome 8. Myotonic dystrophy 9. Porphyria 10. Prader-Willi syndrome 11. Others              4. Gestational diabetes mellitus

 

The third item seems to be the catchall for everything not fitting into the other three classifications. Notice that for all the things listed, prediabetes is not among them. This is only considered a risk for type 2 diabetes and nothing more. “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.”

They then define the blood glucose impairment range as “having impaired fasting glucose (IFG) [fasting plasma glucose (FPG) levels 100 mg/dl (5.6 mmol/l) to 125 mg/dl (6.9 mmol/l)], or impaired glucose tolerance (IGT) [2-h values in the oral glucose tolerance test (OGTT) of 140 mg/dl (7.8 mmol/l) to 199 mg/dl (11.0 mmol/l)].” Then they state that these have been referred to as having prediabetes, but do not go on to use any other term. This is the only use of the word.  They only use the term individuals to describe these people with A1cs of 5.7% to 6.4%. They emphasize that they are to be informed of their risks for diabetes and cardiovascular disease. Like all good doctors, they want them counseled about effective strategies to lower their risks.

So what is purpose of the Expert Committee on Diagnosis and Classification of Diabetes Mellitus?  Is this the end of the use of the term prediabetes and how soon can we expect another term?  All good questions we will have to wait for an answer.  Is it possible we may have another term or will diabetes be expanded to include this range?  Even this discussion on prevention or delay of diabetes only uses the term prediabetes once.  Or will it take another decade or more to make the change?

What Can Be Done for Prediabetes?

Until now, I admit I have gone along with the term prediabetes although I have not liked the term and have called for a change in terms. I feel because of the lack of concern by the medical community and the American Diabetes Association and other organizations, it is time for action and declaring this a condition that needs treatment just like diabetes. Because it has some of the complications of diabetes and risks for others, it is time to just call it diabetes and let medications work to bring it under management.

What brought me to this. Visiting a friend that had a doctors appointment recently. He said that the doctor had said his A1c was 7.2 and that he should watch his food consumption as his sugar was a little high. I had to ask if he would see another doctor? My friend asked why? I told him that I was sorry as I was going to be very blunt, but that the information was telling me that something was wrong. I explained that an A1c reading should have gotten another test – oral glucose tolerance test (OGTT), and if it produced what I thought it would, he had diabetes. My friend said that his family had a history of diabetes on both sides of the family.

We discussed the signs and symptoms and they were there, thirst, frequent urination, and tired feeling. My friend is about 15 pounds above the weight he should be for age, height, and body build. I called my endocrinologist office and asked if they had room for a new patient. After a brief discussion, I put my friend on the phone and they had a longer discussion. He did obtain an appointment for this coming Wednesday, August 8, 2012.

Now he was full of questions. We discussed the OGTT and what he could expect. I said he would have a blood draw, and then he would drink a 75 gram container of glucose and have blood drawn at one and two hours. He would have an A1c done and if his readings were over 200 mg/dl (11.1 mmol/l) at one hour, and his A1c was over 7.0 he would be diagnosed as having diabetes. I said that they would also run a kidney test and maybe several other tests to establish a baseline for the future.

My friend followed me back to my apartment and I loaned him my spare blood glucose meter, a lancing device, lancets, and enough test strips to get him to his appointment.

I then demonstrated how to use the lancet and then load the test strip into the meter and place the test strip to wick up the blood. Since this was about a half hour before he would eat his evening meal, I was surprised by the reading of 247 mg/dl (13.7 mmol/l). I asked him if he had eaten any food since lunch and he said no, he had just finished a coke before seeing me.

I asked him how long his doctor had been telling him his sugar was a little high? He responded about two years. I then asked if he had copies of his lab reports? He said no, he had never been offered them. I explained that he would need to go to the doctors office, make his request in writing for the five years of lab tests, and probably sign a paper and show his driver's license and social security card. Then he would probably wait several weeks to receive them. I explained the reasons for this and that this would help him track his own health. I also explained that they may refer him to the laboratory itself although the doctors office should release them. My friend also said his younger brother and sister should be told. I said when he had results of this tests Wednesday. I said they should also do what you are doing.

About two hours later, he called me and said his sister had just called him that she had been diagnosed with prediabetes, and that he should be tested along with their brother. He asked permission to send his brother and sister my blog site URL and email address and I agreed. I asked if his sister had been started on any medication? He said she told him metformin, and since it was generic it did not cost that much, since her insurance would not cover it for prediabetes.

Too many doctors and far too many patients hear the word prediabetes and think nothing about it. Since the diagnosis is not full-blown diabetes, many doctors and patients just ignore the term and the possible future outcome. Yes, a small percentage of doctors and patients do take this serious, but then cannot find the education to manage the diagnosis and make the right decisions to prevent the onset of diabetes. Then the doctors have no medications other than off-label use which insurance will not cover and thus seldom is a prescription issued.

Current prediabetes range is 100 mg/dl (5.6 mmol/l) to125 mg/dl (6.9 mmol/l). This converts to an A1c reading of 5.7% to 6.4%. Yes, we would all like to have A1c's in this range. This is not the point of this blog. It to galvanize people to insist that the medical community wake up and start treating anyone with a reading in this range as having diabetes. This may be the only way to prevent or lessen the current type 2 diabetes epidemic. Actions by the medical community speak louder than words, and when they start pushing actions, then we will see actions by those with diabetes.

This study demonstrates that actions taken do yield results. By treating early and aggressively, interventions with intensive lifestyle changes or medications (including insulin) do significantly reduce the chances of developing type 2 diabetes in the future. Okay, I can understand you saying this was for prediabetes patients. The fact remains that no medical insurance company will cover medications for prevention, including Medicare. While the study has value, once it ended, no more medications were available until a diagnosis of type 2 diabetes is made. That is the reason for calling for a diagnosis of diabetes at the prediabetes levels.

With the Centers for Disease Control and Prevention (CDC) estimating that about 79 million people having prediabetes, the need for action is here now, and not in the future.

In addition to education for these people, many in the medical community will need education to make them aware of the testing that is needed and that they must diagnose diabetes to get people started on medication. The study needs more dissemination and maybe needs to be repeated, but still should not be ignored as the message is there in black and white and needs action.

Will the American Diabetes Association (ADA) take any action – highly doubtful. Will the American Association of Clinical Endocrinologists (AACE) do anything – more likely, as I have seen actions by some of them already; however, many will still not do what they should. We know that we cannot count on support from the American Medical Association. They have their heads positioned like the ADA where no light can be seen.

More bloggers need to write about this travesty being put on the people with prediabetes (actually I should say diabetes) by the ADA and others.

Steps to Cut Medical Cost for Prediabetes Patients

Maybe someone has finally seen the light in diabetes prevention. This article in WebMD was published on June 28, 2011, but I had missed it until the other day. I hope this gets better recognition and acceptance, as there is a huge cost savings to be had if people with prediabetes can be educated and possibly accept taking Metformin to bring prediabetes under excellent management.

First, the medical insurance industry led by Medicare needs to recognize the potential in the future cost savings. This is because people with prediabetes can manage it quite effectively by a change in lifestyle habits plus exercise. If necessary, they may need to start on the diabetes drug Metformin to give their diabetes management time to be started and become effective. Then once they have made the necessary lifestyle changes and are continuing with an exercise regimen, it may be possible to cease taking Metformin.

Doing this may delay the full onset of type 2 diabetes or if a person becomes proficient in their management of prediabetes, they may be able to postpone the onset of type 2 diabetes for decades or possibly forever. Even some people with early diagnosis of type 2 diabetes are using exercise and diet to avoid medications entirely.

I think the study showed very conservative cost savings, but they are still savings. Those on Metformin alone save $1700 over a decade. Those doing extensive lifestyle changes like participating in tailored weight loss and exercise programs saved $2600 per person. The study also stated that the people who ate right and exercised had the highest scores on the quality-of-life survey that measures physical and mental well-being,

I do not know if this a misprint or not. “The cost-savings analysis comes from seven years of follow-up to the three-year study called he Diabetes Prevention Program (DPP). The study was halted early when both metformin and lifestyle changes far outperformed placebo. The DPP showed that 10 years of treatment with metformin lowered the risk of developing diabetes by 18%, while lifestyle changes reduced the chance by 34%.” This is somewhat confusing if the study was stopped yet they have 10 years of one treatment. Either way this should get more attention as prevention shows cost savings that should not be ignored.

Does Prediabetes Mean Eventually Diabetes?

At least this one subject I can understand and partially agree with the answer given to a prediabetes question. Granted there are some terms that need better definition. This doctor missed a golden opportunity to give a great answer instead of the partial answer.

The question is does prediabetes mean that diabetes will follow. First, the answer that many people do not want to hear. If you do nothing and do not manage prediabetes, it will progress rapidly to type 2 diabetes. That you can count on.

If you take the doctor's answer, you may be able to delay type 2 diabetes for a few years if you do not let denial take over. The doctor talks about making lifestyle changes that can significantly delay or even prevent type 2 diabetes. The answer then goes on to suggest a five to ten percent weight loss. He does explain that this means about 30 minutes of exercise daily and eating healthy meals.

In describing healthy meals, he says nothing about doing any blood glucose testing to see what the food you are consuming does to your blood glucose levels. Then the answer becomes lopsided and the meals he is suggesting becomes very agenda oriented. The agenda excludes any red meat and foods containing any cholesterol. The mantra of egg whites, soy, and whole grains sounds like the American Diabetes Association mantra.

The suggestion of vegetables and fish for foods is acceptable, but do be careful of the quantity of fruit and soy or soy products and especially whole grains. The soy and whole grains can be an overdose of carbohydrates which will undue the benefits of exercise and may well cause weight gain. He says nothing about avoiding highly processed foods and educating yourself to avoid or severely limit potatoes, rice, and bread.

Final suggestions include quitting smoking, drinking alcohol in moderation if you drink and reducing stress to assist in managing your blood glucose levels. The doctor again partially covered the at risks from prediabetes. He mentions heart disease and stokes, but fails to mention any of the other complications that can or may occur in prediabetes. These include kidney damage and eye and hearing problems. Since these vary greatly from one individual to another, it is still wise to know the symptoms and solutions.

Read the short WebMd question and answer here.

Prediabetes and Its Dangers

So you think there is no danger associated with prediabetes? An acquaintance of mine in this small town told me he was not going to worry about the prediabetes diagnosis as there were no dangers associated with it and either you had diabetes or you did not. So sure was he that he constantly reminded the group of us that had type 2 diabetes that he was going to be okay.

Why we continued to accept him and his taunts still bothers me, but we did. I guess we knew that eventually he would change his tune and start asking questions, serious questions. Well that day finally arrived, but not the way we had expected. When he was not present for our get together (now over a month ago), one of the others called his wife and got a shock. He was in the hospital and was in a high blood glucose coma. We do not know how high it was, but we guessed he now had full-blown type 2 diabetes.

We asked if he could have visitors and his wife said the doctor had asked not for that day or the next for other than family. Well, we never did get to see him. Whether we will every know the full story is doubtful, but that night he passed. His wife said that their two children had arrived after work so she was on her way home to clean up and return. On her way home, their son called and said Dad was gone.

We know a little more, his heart had failed and they had been told that his kidneys were in poor condition. I have been researching and yes, cardiovascular disease does dramatically increase with prediabetes, retinopathy can develop, and kidney health can be impaired. Many with prediabetes can develop diabetic neuropathy or peripheral neuropathy. Not quite what I had expected for prediabetes. Again, this is a reminder that everyone can be affected differently when it comes to prediabetes and type 2 diabetes.

Which leads me to the question – why not treat it as diabetes. I'm sure the American Diabetes Association will not have an answer.

We have also learned that our friend had high blood pressure and had stopped taking his medications. Could we have done more for him? We have talked about this and have decided that for him we had done all we could have under the circumstances, as he would not have listened to us. How will we treat future people that come to the fringes of our group? We will invited them in if they have a diagnosis and work to get them past denial if they are in denial. Will we be successful – remains to be seen. We just know that we will make every attempt.

We have checked the books on diabetes at our local library and they will be acquiring two more books at our request to supplement the ones they have. We are investigating other activities like making our informal group a little more known and possibly working with doctors in nearby towns if they are open to this.

This WebMD article is available as a reference on prediabetes.