The incidence
of prediabetes is rising. Approximately one third of the people in the United
States have prediabetes, 80% of whom do not even know they have the condition. It
is important to treat prediabetes because, in addition to being a risk factor
in developing type 2 diabetes, prediabetes is a severe metabolic condition that
affects the heart, kidney, and liver.
What Is
Prediabetes?
Prediabetes
is diagnosed when one has a higher-than-normal blood sugar level but not high
enough to be in the diabetic range. (In prediabetes, the hemoglobin A1C (HbA1C),
the three-month average blood sugar, is between 5.7% and 6.4%. Diabetes is
diagnosed when patients have a HbA1C of 6.5 or greater at two different times.)
Our
body uses glucose, a simple sugar that comes from the food we eat, as its
primary fuel source. Insulin, produced by the pancreas in response to food
intake, drives glucose into the cells, where it is burned to create energy. When
someone has prediabetes, the process does not work well. The cells do not
respond properly to insulin, and instead of glucose entering the cells, a
significant amount builds up in the blood stream. This happens either because
the cells are resistant to insulin or the pancreas does not make enough
insulin. The more common case is the first scenario.
Who Gets
Prediabetes?
An
important risk factor for prediabetes is being overweight or obese. A large
waist size may indicate insulin resistance. The risk of insulin resistance
rises for men with waist sizes of larger than 40” and women with waists bigger
than 35”. Eating red meat, processed meat, and sugar sweetened beverages
increases the risk of prediabetes. Family history of diabetes, inactivity,
smoking, being older than 45, and patients with obstructive sleep apnea – along
with women who have a history of gestational diabetes – have higher risks for
prediabetes. Interestingly, the child of a woman with gestational diabetes is
also at higher prediabetes risk.
Patients
with prediabetes have a higher risk of developing diabetes. A major goal for
patients is to prevent them from developing diabetes. However, prediabetes is
not simply a way station on the path to diabetes but a severe metabolic
condition in its own right. Patients with prediabetes have 25% higher odds of
having a heart attack than those with normal blood sugar. Not only is there
increased risk for cardiovascular disease, but patients with prediabetes have
up to twice the risk of developing chronic kidney disease and a higher risk of
developing fatty liver disease. Finally, prediabetes carries with it a 13%
increased death rate from all causes. The diagnosis of prediabetes should therefore
be a warning sign for patients. It is insufficient to only hold off the
diagnosis of diabetes as patients still face significant risks in multiple
other areas.
Treating
Prediabetes
What
can be done to reverse prediabetes? Lifestyle Medicine is a medical specialty
that mainly uses therapeutic lifestyle interventions to treat and when used
intensively to reverse chronic conditions such as cardiovascular disease and
diabetes. The six pillars of Lifestyle Medicine that can help to prevent
chronic disease are 1) a predominantly plant-based eating pattern, 2)
physical activity, 3) restorative sleep, 4) stress management, 5) positive
social connections, and 6) avoiding risky substances.
According
to the American College of Lifestyle Medicine, “Extensive scientific evidence
supports a whole-food, predominantly plant-based eating plan as an important
strategy in preventing chronic disease, treating chronic conditions, and, in
intensive therapeutic doses, reversing chronic illness. Such an eating plan is
rich in fiber, antioxidants, and nutrient-dense, with a variety of minimally
processed vegetables, fruits, whole grains, legumes, nuts, and seeds.” The
goal is to reverse insulin resistance to make cells more sensitive to insulin.
Instead
of eating sugary treats, sugar sweetened beverages, or ultra-processed foods,
it is recommended that we eat whole grains, brown rice, beans, barley, oats, and
quinoa and decrease unhealthy processed foods. These include commercially made
bread, cookies, sodas, candy, and frozen meals. It can be very helpful to eat a
whole grain food rather than a piece of white bread. We also need to
concentrate on fiber, which slows down digestion and glucose absorption.
Examples are vegetables like broccoli, carrots, celery, cucumbers, mushrooms,
sweet potatoes, leafy greens, tomatoes, and radishes. Remember, fiber is only
present in plant products, not in animal-based foods.
Because
being sedentary is a risk factor for prediabetes, we recommend increasing
exercise at a moderate pace of up to 150 minutes weekly or an average of 30
minutes five times weekly. Moderate exercise is the equivalent of a brisk walk.
One can split up the day’s exercise as the total can be reached even over
multiple sessions. Even if one satisfies the aerobic portion of exercise, it is
still possible to be sedentary. One should not sit for many hours without a
break. A good rule of thumb is to get up and walk five minutes every hour. One
should also do muscle strengthening exercises twice weekly. Start slowly and
gradually build up.
With
the combination of a whole food, plant-based diet and adequate exercise, the
abdominal fat and waist size will decrease as well as the overall weight. One
must be aware that in the beginning of the path of prediabetes reversal,
despite one’s best efforts, one will likely lose inches before pounds.
For
those who smoke, it is extremely important to quit as this is a known risk
factor for prediabetes as well as other health conditions, such as cancer and
heart disease. Lowering stress levels is important as is getting a good night’s
sleep. Reactions to stress, such as overeating, drinking excessive alcohol, skipping
exercise, and sleeping less are harmful to blood sugar control. Exercise as
well as healthy eating can help one cope with stress. It is not the stressful
event per se that is most important but how it affects an individual patient.
The goal is not to totally be rid of stress but to manage it in healthier ways,
such as deep breathing and meditation.
Since
prediabetes is so common and most people do not recognize that they have it,
anyone with risk factors – being over 45, inactivity, male gender, high blood
pressure, family history of diabetes, smoking, and overweight/obesity – should see
their physician or medical provider and be tested. By making more people aware
that they have prediabetes, we can start the reversal process earlier, prevent
complications, and live healthier lives.
Dr. Birnbaum practices Internal Medicine with
Lifestyle Medicine and sees patients at Johns Hopkins at Water’s Edge in
Belcamp, MD in Harford County.
