Guidelines for Pre-diabetes

Diagnosis and Management

 What is pre-diabetes?
When a person's blood glucose levels are
higher than normal but not high enough for a
diagnosis of diabetes

“Borderline diabetes”
“A touch of sugar”

PRE-DIABETES
 ADA Diagnostic Criteria for Diabetes
Clinical Practice Recommendations 2010
1. A1C ≥6.5%. The test should be performed in a laboratory using a
method that is NGSP certified and standardized to the DCCT assay.*

OR
2. FPG ≥126 mg/dl. Fasting is defined as no caloric intake for at least
8 h.*
OR
3. 2-h plasma glucose ≥200 mg/dl during an OGTT. The test should
be performed as described by the World Health Organization, using a
glucose load containing the equivalent of 75 g anhydrous glucose
dissolved in water.*
OR
4. Random plasma glucose ≥200 mg/dl in a patient with classic
symptoms of hyperglycemia or hyperglycemic crisis.
In the absence of unequivocal hyperglycemia, criteria 1–3 should be confirmed by repeat testing.
 How is pre-diabetes diagnosed?
Categories of increased risk for diabetes

Impaired Fasting Glucose [IFG]: Fasting Plasma

Gluocse 100–125 mg/dl
Impaired Glucose Tolerance [IGT]: 2-hour Plasma
Glucose on the 75-g Oral Glucose Tolerance Test
140–199 mg/dl

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.
 ADA Diagnostic Criteria:
Normal, Diabetes, and Pre-diabetes
Clinical Practice Recommendations 2010

Parameter Normal Diabetes Pre-diabetes Method

1 Fasting Plasma <100 ≥126 100–125 No caloric intake

Glucose (mg/dl) for at least 8 h

2 2-h plasma <140 ≥200 140–199 WHO method: 75

glucose on g glucose load
OGTT (mg/dl)
3 Random plasma <140 ≥200 - with classic
glucose (mg/dl) symptoms
of hyperglycemia
or crisis
4 A1C <5.7 ≥6.5 5.7 – 6.4 NGSP certified
% method
standardized to
the DCCT assay

In the absence of unequivocal hyperglycemia, criteria 1, 2, and 4 should be confirmed by repeat testing.
 The Epidemic of
Diabetes and Pre-diabetes

• Diabetes: 26 million (11.3%) and increasing.

• By 2015, 37 million (15%) Americans will have diabetes
• Pre-diabetes: 57 million: About 1/4 (22.6%) of
overweight adults aged 45–74 (CDC data)
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf
http://www.cdc.gov/diabetes/pubs/factsheets/prediabetes.htm
 Pre-Diabetes in the
Young and the Old
• The diabetogenic process begins early –
low birth weight and poor nutrition

• Diabetes epidemic due to:

-lack of exercise and overweight in
young persons, and
-aging of the population

• Correlation with central obesity, insulin

resistance, glucose intolerance, high
blood pressure , and dyslipidemia –
metabolic syndrome
 The Metabolic Syndrome:
National Cholesterol Education Program – Adult
Treatment Panel (NCEP ATP III) Criteria
(May 2001 Guidelines) NCEP ATP III. JAMA.
2001;285:2486-2497.

3 of the Following
Risk Factor Defining Level
Abdominal Obesity (waist circumference)
Men >40 inches (102 cm)
Women >35 inches (88 cm)
Triglycerides 150 mg/dL
HDL Cholesterol
Men <40 mg/dL
Women <50 mg/dL
Blood Pressure 130/85 mmHg
Fasting Glucose 110 mg/dL
 What are the health risks associated
with pre-diabetes?
• Progression to diabetes: on average, 11% of
people with pre-diabetes develop type 2
diabetes each year (DPP)
• Other studies: majority with pre-diabetes
develop type 2 diabetes in 10 years
• Presence of microvascular complications at
onset of diabetes
• 50% higher risk of CVD: CAD and stroke
 CDC Data
http://www.cdc.gov/diabetes/pubs/factsheets/prediabetes.htm
accessed June 2010

Among adults with pre-diabetes in 2000, the prevalence

of cardiovascular (heart) disease risk factors was high:

94.9% had dyslipidemia (high blood cholesterol);

56.5% had hypertension (high blood pressure);

13.9% had microalbuminuria

16.6% were current smokers

 Who should get tested for pre-
diabetes?
• Age 45 or older
• Overweight
• Family history of diabetes
• Other risk factors for diabetes or pre-diabetes:
sedentary lifestyle, hypertension, low HDL
cholesterol, high triglycerides, history of gestational
diabetes or giving birth to a baby weighing more
than 9 pounds, or belonging to an ethnic or minority
group at high risk for diabetes
 Acanthosis Nigricans:
a Sign of Insulin Resistance
• Velvety, light-
brown-to-black
discoloration usually
on the neck, axilla,
groin, dorsum of
hands
• May point to PCOS
in females
• Insulin sensitivity
decreases by 30% at
puberty with
compensatory
increase in insulin
secretion
 How often should be testing done?

• Every 3 years if glucose tolerance is normal

• Every 1-2 years if pre-diabetes is diagnosed
 What is the Treatment for
Pre-diabetes?
• Pre-diabetes is a serious medical condition!
• It CAN be treated
• TRIALS: Da Qing 1997, Finnish study 2001, DPP 2002:
persons with pre-diabetes can prevent the
development of T2DM by sustained lifestyle changes
• 5-10% reduction in body weight coupled with 30
minutes a day of moderate physical activity
• Reversal of pre-diabetes and return of blood glucose
levels to the normal range is possible
“I have bad genes”
Pharmacologic Treatments for Pre-diabetes

• Since many individuals with pre-diabetes are generally

healthy, benefits of preventive therapy must outweigh any
associated side-effects or risks
• Expense
• None are FDA-approved
Agent Study RRR Side-effects
Metformin Da Qing, 28% GI
Glucophage Finnish, DPP
Acarbose STOP-NIDDM 25% GI, poor
Precose compliance
Rosiglitazone DREAM 62% Bone loss,
Avandia edema, CHF
Orlistat XENDOS 52-62% GI, poor
Xenical, Alli compliance
 ADA Consensus Statement:
Preventive treatment in high-risk
individuals with pre-diabetes
Diabetes Care 2007

In addition to lifestyle modification, the

following individuals should be considered for
treatment with metformin:
-those who have both IFG and IGT, and
-at least one additional risk factor (age <60,
BMI ≥35, FH of diabetes in first degree
relative, elevated TGs, reduced HDL, or A1C
>6%
 Preventive Strategies and Evidence-
based Interventions that make sense
• Changes at the individual level

• Community- and population-based

Conflicting Messages!
Thank You