A Doctor’s Diagnosis: Prediabetes

Jane is one of my patients and her story is similar to millions in the United States. She’s a 47-year-old mom who has been coming to me for the past 10 years. Jane is somewhat overweight and has been struggling with one diet or another since I have known her.

In the first few years, she was exercising regularly and aggressively. At times, Jane lost a few pounds, which she usually regained with the all too frequent relaxation of her diet. She attributed her weight gain to a hormone imbalance. At age 42, I diagnosed Jane as being hypothyroid, a condition resulting from low thyroid hormone production, causing low metabolism. I treated her with a replacement dose of thyroid hormone. While Jane felt better, her weight did not change. To lose the extra weight, she not only needed to exercise but also reduce the amount of calories she consumed.

“Do you know how hard that is?” Jane asked. “As a mom, I’m always on the go. It’s difficult to find the time to exercise.”

“I completely understand,” I said. “But regular exercise is a necessity if we’re going to protect you from developing diabetes, heart disease or both.”

I did not see Jane for two or three years, until she came to see me about six months ago. As usual, she was pleasant, but remained overweight and had gained about five pounds. Jane told me that she had been unable to find the time to exercise because she was actively preparing her daughter for college. Knowing that Jane had a family history of diabetes and heart disease, I stressed the importance of exercise.

“I am still a young woman,” she said. “I should not have to worry about heart disease, at least not yet.”

Jane is a registered nurse and knows a lot about different medical conditions, so I felt comfortable speaking with her frankly: “The last blood test you had a few years ago showed a fasting glucose (blood sugar) level of 106. This level used to be considered normal but now is defined as impaired fasting glucose or IFG,” I said. “This makes you part of a group of people who are also defined as having “prediabetes.” It indicates that your body has a problem dealing with sugar and carbohydrates. In fact, you’re at risk for developing diabetes and perhaps cardiovascular disease. You also have a greater risk of other complications of the kidney and eye as well as nerve damage (neuropathy).”

Astounded, she asked, “You mean that I’m at risk for developing diabetes?”

“Yes,” I told her.

This news came as quite a shock to Jane. She had a lot of questions about treating her condition and reducing her risk for heart disease and other complications. Jane wanted to be proactive and try to prevent diabetes and heart disease. However, before discussing the specifics, I decided to examine Jane again and repeat laboratory tests. A few days later, we reviewed the results together. Jane’s blood pressure was marginally elevated at 137/84 and her fasting glucose level was 118. The tests also showed that her bad cholesterol (LDL) was high at 151 and that her good cholesterol (HDL) was somewhat low for a woman at 42. Her TGL level, which measures the triglycerides or the amount of fat in the blood, was also high at 175. An ultrasound of the carotid (neck) arteries revealed some plaque formation indicating hardening of the arteries.

We sat down to discuss the impact on her health. I told Jane that while she did not have diabetes at that time, she clearly had prediabetes. I explained that she had many typical risk factors for heart disease, including marginally elevated blood pressure and some lipid abnormalities. Although she did not have known heart problems, the process leading to heart and blood vessel disease had started. Jane already had some hardening of the arteries with cholesterol, a condition known as atherosclerosis.

She wondered what she could do to prevent the onset of type 2 diabetes and stop the progression of heart disease. Even though Jane was a relatively young woman, who had marginally elevated blood pressure and some lipid problems, she was already at high risk to develop heart disease. We discussed her treatment options. I talked to her specifically about the recommendations for the management of prediabetes that were recently developed by the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE). Based on these recommendations, I was able to answer Jane’s questions about prediabetes:

Who is at risk for developing prediabetes?

  • Individuals with a non-Caucasian ancestry
  • Individuals with a family history of diabetes
  • Individuals with impaired glucose levels and/or metabolic syndrome
  • Individuals with cardiovascular disease, hypertension (high blood pressure), increased levels of triglycerides, and/or low levels of good cholesterol (HDL)
  • Individuals who are overweight or obese
  • Women who have had gestational diabetes, had high birth weight babies (greater than 9 lbs.), and/or has Polycystic Ovarian Syndrome (PCOS)

What are the risks of not treating prediabetes?

  • Cardiovascular disease, including heart disease, stroke, and blood vessel disease
  • Other complications include eye disease, kidney disease and nerve damage

How can I reduce my risk for developing prediabetes?

  • By taking a two-track approach to prevention:
  • Lower blood glucose to stop the progression of diabetes and prevent complications
  • Address cardiovascular disease risk factors by treating lipid disorders (high cholesterol) and blood pressure

What lifestyle modifications do I need to make to reduce my risk?

  • Create a moderate-intensity physical activity program that lasts for 30 to 60 minutes and is completed at least five days a week.
  • Make diet adjustments, including calorie restriction, limiting carbohydrates, and increasing fiber intake.
  • Individuals with prediabetes should reduce their weight by 5 to 10 percent.
  • Visit your physician to monitor blood sugar, lipid levels, and blood pressure a least once a year. Individual at a higher risk should do this more frequently.

Are there medications approved to treat prediabetes?

  • While there are not any medications currently approved by the Food and Drug Administration (FDA) to treat the elevated glucose in prediabetes, drug therapy to lower blood sugar is sometimes considered in high risk patients.
  • Low-dose aspirin is recommended for all people with prediabetes who do not have an increased risk of bleeding.

Once I finished answering her questions and reviewing the recommendations about managing prediabetes, Jane was ready to take the next step toward living a better life. She agreed to eat healthier foods and stay away from sweets and “junk food.” Jane also decided to start exercising at least three times a week. I encouraged her to increase her exercise program from three days to five days a week over time. I prescribed medication for cholesterol to try to stop the progression of atherosclerosis (hardening of the arteries) as well as low-dose aspirin. Jane was to return to the office after three months to determine the effectiveness of lifestyle modifications on her blood pressure and glucose levels in order to assess her potential need for medications.

I wished her luck and encouraged her lifestyle modifications, since this was the toughest part of treatment but the most rewarding. With the knowledge she gained, Jane now possessed everything she needed to lead a healthy and successful life.

Yehuda Handelsman, MD, FACP, FACE, is an endocrinologist in solo practice in Tarzana, California. He is the Medical Director of the Metabolic Institute of America and Senior Scientific Consultant, at the Metabolic Endocrine Education Foundation. Dr. Handelsman is founder and chair of the International Committee for Insulin Resistance. He is Associate Editor of the “Journal of Diabetes,” an International peer-reviewed journal based in China, and devoted to diabetes research, therapeutics, and education. Dr. Handelsman is on the editorial board of “Clinical Endocrine News,” has been a reviewer for several publications and position papers, and was a guest editor of a special issue of the journal “Metabolic Syndrome and Related Disorders.”