In addition to the worldwide pandemic of obesity and diabetes, there are an estimated 314 million people with pre-diabetes. In the US, 57 million people have pre-diabetes, defined as impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT). Pre-diabetes raises the short-term absolute risk of type 2 diabetes by three- to 10-fold. In and of itself, pre-diabetes predisposes people to microvascular (retinopathy, neuropathy, nephropathy) and macrovascular (cardiovascular) disease. Patients with pre-diabetes may already exhibit evidence of retinopathy and microalbuminuria.
In addition to the worldwide pandemic of obesity and diabetes, there are an estimated 314 million people with pre-diabetes. In the US, 57 million people have pre-diabetes, defined as impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT). Pre-diabetes raises the short-term absolute risk of type 2 diabetes by three- to 10-fold. In and of itself, pre-diabetes predisposes people to microvascular (retinopathy, neuropathy, nephropathy) and macrovascular (cardiovascular) disease. Patients with pre-diabetes may already exhibit evidence of retinopathy and microalbuminuria. Patients with a diagnosis of IGT, IFG, or metabolic syndrome convert to diabetes in the order of 8–10% per year; if all three diagnoses are present, conversion rates exceed 10% per year. Conversion of IFG to diabetes increases cardiovascular disease mortality two-fold.
Until recently, there were no guidelines on the need to identify people with pre-diabetes and proactively manage the associated risks of pre-diabetes. The American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE) are taking steps to highlight the risks of pre-diabetes, establish recommendations on who should be screened and how they can be screened, and make recommendations for the proactive management of such individuals. A consensus statement, pending full publication in Endocrine Practice, highlights the need to screen all patients at risk for diabetes for the presence of pre-diabetes. In the spectrum from pre-diabetes to diabetes, IGT is further along the path to diabetes than IFG. The presence of metabolic syndrome features also predicts diabetes; two or more features should be considered a pre-diabetes equivalent. Having more than one of IFG, IGT, or metabolic syndrome increases a patient’s risk.
What can and should be done for such patients? The importance of lifestyle management—both diet and physical activity— cannot be overemphasized. Clinical trials have demonstrated the clinical and health-economic benefits of preventing progression to diabetes through lifestyle intervention. Exercise not only influences the glycemic risk of pre-diabetes, but also reduces the macrovascular risks associated with pre-diabetes. In fact, the ACE and the AACE advocate a two-pronged approach to reducing the risk for pre-diabetes, with an equal emphasis on glycemia and modification of cardiovascular risk factors (i.e. hypertension and dyslipidemia). Blood pressure and cholesterol goals for those with pre-diabetes should be the same as those for patients with established diabetes. Although no medications are approved for the treatment of pre-diabetes, some patients at higher levels of risk who do not respond adequately to lifestyle intervention may need pharmacotherapy to manage glycemia and/or blood pressure and cholesterol. The AACE also understands the importance of implementing wellness policies and is proud to be co-ordinating the ‘Power of Prevention,’ a free program designed to show the benefits of physical activity and proper nutrition in various endocrine-related disorders.
Finally, there is recognition that additional research is needed to stem the diabetes epidemic and its predecessor, pre-diabetes. These include determination of any unique characteristics that might distinguish different levels of risk for conversion to diabetes and development of cardiovascular disease, and efforts to improve diagnostic as well as therapeutic options.
US Endocrinology would like to thank all contributors to this edition and specifically the individual authors for their time and effort in providing informative and thought-provoking articles. We hope you find this edition a useful and interesting read.â–
