Definition
A.Failing pancreatic islet beta cells.
B.State of insulin resistance.
C.Caused by excess body weight, usually abdominal/visceral obesity.
D.Dyslipidemia.
E.Elevated triglycerides.
F.Low high-density lipoprotein (HDL) cholesterol.
G.Hypertension.
Incidence
A.In 2012, 86 million Americans age 20 and older had prediabetes; this is up from 79 million in 2010.
Pathogenesis
A.Insulin resistance. There is a marked decrease in insulin sensitivity 5 years prior to diagnosis of type 2 diabetes.
B.Relative insulin deficiency; beta cell dysfunction. Beta cell function is increased 3 to 4 years prior to the diagnosis of diabetes and then decreased immediately prior to the diabetes diagnosis.
Predisposing Factors
A.Obesity.
1.Body mass index (BMI) greater than 25 in all but Asians.
2.BMI greater than 23 in Asian Americans.
B.First-degree relative with diabetes.
C.Higher risk in certain ethnic populations.
1.African Americans.
2.Latino.
3.Native Americans.
4.Asian Americans.
5.Pacific Islanders.
D.Women with history of gestational diabetes.
E.History of cardiovascular disease.
F.Hypertension greater than 140/90 mmHg.
G.HDL less than 35 mg/dL.
H.Triglycerides greater than 250 mg/dL.
I.Women with history of polycystic ovary syndrome.
J.Women who have given birth to a baby weighing over 9 lbs.
K.Physically inactive.
L.Physical findings of insulin resistance.
1.Skin tags.
2.Acanthosis nigricans (see Figure 8.1).
M.Obstructive sleep apnea.
N.Can have patient take American Diabetes Association risk test at www.diabetes.org.
Subjective Data
A.Common complaints/symptoms.
B.Usually asymptomatic.
C.Patient may present for routine physical or preoperative assessment.
Physical Examination
A.Record height, weight, BMI, waist circumference, waist to hip ratio.
B.Monitor for abdominal obesity.
C.Assess for signs of cardiovascular disease and peripheral vascular disease.
D.Check for the following signs/symptoms.
1.Premature arcus cornealis.
2.Xanthelasma.
3.Polycystic ovarian syndrome symptoms.
a.Acne.
b.Hair loss.
c.Hirsutism.
4.Acanthosis nigricans (see Figure 8.1).
5.Presence of skin tags.
Diagnostic Tests
A.Hemoglobin A1C (HgbA1C): 5.7% to 6.4%.
B.Fasting glucose: 100 to 125 mg/dL.
C.Random glucose: 140 to 199 mg/dL.
Differential Diagnosis
A.Metabolic syndrome.
B.Type 2 diabetes.
C.Obesity.
D.Hypertension.
E.Hyperlipidemia.
Evaluation and Management Plan
A.General plan: Lifestyle therapy.
1.Treat cardiovascular risk factors.
a.Dyslipidemia.
b.Hypertension.
2.Weight loss/management.
a.This can be achieved through lifestyle, pharmacotherapy, surgery, or a combination of treatments.
b.Bariatric surgery can be very effective in preventing progression of prediabetes to type 2 diabetes.
3.Nutrition therapy.
4.Physical activity.
5.Sleep.
6.Community engagement.
7.Alcohol moderation.
8.Smoking cessation.
B.Pharmacotherapy.
1.No medications are approved by the Food and Drug Administration solely for the management of prediabetes and the prevention of type 2 diabetes.
2.Medications should not be considered the only therapy. All medications should be combined with lifestyle modifications.
3.Metformin reduces risk of type 2 diabetes mellitus (T2DM) in prediabetes patients by 25% to 30%.
4.Acarbose reduces risk of T2DM in prediabetes patients by 25% to 30%.
5.Consider with caution use of thiazolidinediones (prevent development of type 2 diabetes by 60%–75%) or glucagon-like peptide-1 (GLP-1) receptor agonists.
Follow-Up
A.Follow-up with primary provider as needed to manage risk factors.
Consultation/Referral
A.Refer the patient to a registered dietician for diet education/counseling.
B.Refer the patient to a psychologist/counselor for stress reduction and life coaching.
C.An exercise physiologist may help with planning a realistic exercise program.
D.Refer the patient to a lipid clinic for management of hyperlipidemia.
Special/Geriatric Considerations
A.The risk of diabetes increases with age.
B.Microvascular and cardiovascular complications are more common in the elderly and should be monitored closely.
Bibliography
Bock, G., Dalla Man, C., Campioni, M., Chittilapilly, E., Basu, R., Toffolo, G., … Rizza, R. (2006). Pathogenesis of pre-diabetes: Mechanisms of fasting and postprandial hyperglycemia in people with impaired fasting glucose and/or impaired glucose tolerance. Diabetes, 55, 3536–3549. doi:10.2337/db06-0319
Grundy, S. M. (2012). Pre-diabetes, metabolic syndrome, and cardiovascular risk. Journal of the American College of Cardiology, 59(7), 635–643. doi:10.1016/j.jacc.2011.08.080