What primary care should know about prediabetes prevention

The latest National Diabetes Statistics Report, 2017 found that 30.3 million people have diabetes-almost 10% of the population-and that an estimated 34% of adults have prediabetes.

Primary care physicians (PCPs) have a major role to play in diabetes prevention, says endocrinologist Thomas W. Donner, MD, director of the Johns Hopkins Diabetes Center and associate professor of medicine at Johns Hopkins Medicine in Baltimore.

Donner recently spoke with Medical Economics regarding what PCPs should know regarding the possibility of a prediabetes diagnosis for their patients.

Q: Why is diabetes prevention so important?

Thomas W. Donner, MD: If you prevent diabetes from developing, the risk of complications can be dramatically reduced. Diabetes is the leading cause of vision loss in adults, along with kidney failure and non-traumatic amputations, and is a leading cause of heart disease. The latest rate of progression from prediabetes to diabetes is 5% to 10% per year. That's a measure of the patient population that has been diagnosed with prediabetes each year that will go on to develop diabetes if no intervention is performed. Interventions are quite effective at reducing the rate of progression, so identifying patients at risk for prediabetes and diabetes is most important.

Q: Where does this start?

Thomas Donner, MD

Donner: Screening persons at high risk is very important and of course, glucose is part of a metabolic panel. Patients with prediabetes should have annual monitoring, according to the latest Standards of Medical Care of Diabetes  from the American Diabetes Association. The standards suggest that: "Those determined to be at high risk for type 2 diabetes, including people with A1C 5.7%–6.4% (39–47 mmol/mol), impaired glucose tolerance, or impaired fasting glucose, are ideal candidates for diabetes prevention efforts."

The Diabetes Prevention Program found lifestyle interventions to be even more effective than therapy with Metformin in preventing progression to diabetes. Metformin is usually the first medication for treatment of type 2 diabetes in adults and is typically used in conjunction with diet and exercise. It addresses insulin resistance, making tissues more sensitive to insulin and helps prevent the liver from producing excess sugar, which is seen in prediabetes and diabetes.

Lifestyle changes found to be effective include a diet that leads to a weight loss of 7% or more, paired with at least 150 minutes of moderate intensity exercise per week.

(Note: The Centers for Disease Control and Prevention define moderate intensity as walking briskly, 3 miles per hour or faster, but not race-walking; water aerobics; bicycling slower than 10 MPH; tennis (doubles); ballroom dancing and general gardening.)

Next: Understanding the risks

Q: Who is most at risk for development of diabetes?

Donner: Women who have a prior history of gestational diabetes; persons who are over age 45; are overweight; have a first-degree family member with diabetes; or have cardiovascular disease, high blood pressure, high triglycerides or low HDL cholesterol would benefit from screening for diabetes.

Q: What else should patients with prediabetes and diabetes be concerned about?

Donner: Heart disease is the leading cause of death in patients with both conditions. Patients whose blood sugar is in the prediabetes range, who also have elevated blood pressure or cholesterol, should strongly be considered for blood pressure and cholesterol-lowering medication. Taking care of cardiovascular risk factors is an equally important component of diabetes prevention and care.

Q: What can families do to help prevent prediabetes and diabetes?

Donner: If one person is identified as having prediabetes, it's more likely others in the family will have it. It's important for family members-especially children-to establish healthy lifestyle habits of eating well and being physically active. It's helpful for the entire family to focus on a healthy lifestyle together, instead of just the individual doing so.

As physicians, we look for motivators to get people to take medications and improve lifestyle behaviors. I like to tell patients to consider that their healthy behaviors may positively affect the ones they love.