When travelers reach crossroads, they need to choose a direction to take. Should they forge ahead, make a turn or go back and retrace their steps? Patients who have blood sugar levels that are borderline high are in a similar position, for there is still a chance to reverse their glucose level to normal in many cases, rather than go forward to develop overt diabetes or continue at the borderline level.
The views expressed are those of the author and do not necessarily
reflect the position of Re:solve Global Health.
Diabetes Mellitus type 2 is rising globally due to various reasons such as the rising prevalence of overweight and obesity, sedentary lifestyles, and increasing life expectancy. The best way to curb this is to start intervention at the prediabetes or “impaired glucose” stage. Both patients and healthcare providers should be actively involved in identifying and reversing this stage to avoid progression to overt diabetes.
There are many undetected, and thus untreated patients with impaired glucose levels, and this generally occurs at about the same rate or at an even higher prevalence than overt diabetes in some regions of the world. Before the Covid-19 pandemic, as many as 50% of patients with high blood glucose remained undiagnosed based on the data from the 2019 International Diabetes Federation Atlas. When following up with patients classified as “at risk for diabetes” in a diverse population, progression to diabetes occurs in 25% of them over three to five years. Among the higher risk groups, such as many Asian populations, around 68% can progress to overt diabetes within six years if clinicians do not initiate a treatment strategy.
Identifying those at risk
Who is at risk for developing high blood sugar levels? Should we be testing all adults? In addition to the factors already mentioned, a number of factors put a person at risk for prediabetes and overt diabetes: a family history of diabetes in first-degree relatives; high blood pressure; cardiovascular disease; prior history of elevated blood glucose, especially among women who have this condition during pregnancy; polycystic ovary syndrome/ metabolic reproductive syndrome; fatty liver disease or abnormal lipid levels; and long-term use of medications such as glucocorticoids and anti-depressants. Screening for pre-diabetes should be done for people with these risk factors regardless of age. The high-risk ethnic groups include Asians, Asia-Pacific islanders, African Americans, Native Americans, and Latin Americans. People should be screened regularly for elevated blood sugar levels starting age 40 if they belong to these ethnicities.
Why early detection and treatment matter
More action is needed to diagnose patients, because the treatment is widely and readily available in the form of lifestyle changes, including good nutrition and regular exercise to either reduce elevated body weight, or to maintain normal weight. Various pharmacological treatments have also been studied and are available and affordable. Overwhelming numbers of large population-based research and long-term studies with lifestyle changes and drug intervention have already shown the risks of prediabetes and the benefits of addressing it early and definitively. Unfortunately, there is clinical inertia on the part of both patient and healthcare providers in starting, as well as intensifying, therapy. Although the most worrying clinical consequence is the progression to diabetes, people with impaired glucose metabolism have also been shown to be at some risk for developing comorbidities; these can include cardiovascular events, stroke, cancer, depression, kidney, and nerve diseases, albeit not at the same magnitude as those with overt diabetes. Reversing prediabetes back to normal glucose level should be the objective. By treating and monitoring people at risk for diabetes in their impaired glycemic stage, both patients and healthcare systems will have reduced the burden of diabetes and its staggering number of complications, such as leg amputations, blindness, kidney failure and stroke.
Increasing awareness
The cornerstone of prediabetes therapy is education and awareness for the patients, their families and caregivers, and health care providers about the specific strategies and targets for lifestyle intervention and the timely initiation of pharmacotherapy if lifestyle intervention fails. Support systems should be put into place at the community level as well, for these interventions to work. Both the US Centers for Disease Control (CDC) and EU countries have patient support programs and government-funded or private health provider-financed programs to address the challenges of lifestyle intervention. The programmes they are implementing are based on protocols used in the American Diabetes Prevention Program study using intensive lifestyle therapy and pharmaceutical treatments, and the Finnish Diabetes Prevention Program, respectively. For the Asian cohorts, the DaQing study from China and the Indian Diabetes Prevention Program using moderate lifestyle intervention also showed benefit in preventing progression to diabetes. Recognizing the diversity in cultural food preferences and practices across the different regions, the recommendations for nutrition may vary but are all aimed to achieve the overall goal of weight loss or weight maintenance, healthier food choices, regular exercise, smoking cessation, sleep hygiene, and the need for more frequent monitoring of risk factors.
When lifestyle changes fail to reverse the glucose back to normal after 6 months, it is ideal to start pharmacotherapy. Many medications have been studied and these options can be discussed with the attending physician.
The United Nations considers diabetes to be a major non-communicable disease and has designated November 14 as UN World Diabetes Day, but intervention at the prediabetes stage is paramount to halt this metabolic epidemic. Cost effective studies done in the United Kingdom, USA, Japan, and Singapore have already proven that managing prediabetes by halting its progression to diabetes is beneficial not just for the patient, but for their respective healthcare systems.
It is apt to term prediabetes as the “sugar crossroad” where prompt detection and intervention can alter the course of the journey. The patient may be the traveler at the junction, but making him or her reverse direction toward normal glucose levels requires support from family, healthcare providers and policymakers. Lifestyle changes and timely initiation of medication to bring back and maintain blood sugar at normal levels is the key to success.