Pre-diabetes affects one in six of your adult patients. Pre-diabetes is part of the type 2 syndrome (central overweight, abnormal glucose, hypertension, dyslipidaemia and thrombogenesis). Pre-diabetes is a marker of increased risk of future cardiovascular events and diabetes. Pre-diabetes should prompt review of lifestyle and medical risk factors and interventions to reduce future problems.

Pre-Diabetes: A New Challenge

Australians are world champions coming in, first, second and third.1st Olympic nation. 2nd fattest developed nation (US wins).3rd least active nation (UK wins).First is good news. Runners up are losers.Now overweight/obese Australians outnumber and greatly outweigh, healthy weight Australians (figure 1)1. Associated with or causative of this overweight is inactivity. All developed nations are walking less in this age of the car, the remote and the escalator but Australians are doing less than most. Associated with fatness and inactivity comes the diabetic epidemic (figure 1).To view Figure 1, The Rise & Rise of Diabesity click here

Pre-diabetes – the type 2 diabetes syndrome.

As we get fatter and less active we develop the Type 2 Diabetes Syndrome. This includes central overweight, abnormal glucose metabolism, hypertension, dyslipidaemia and thrombogenesis (figure 1).Identifying those at risk is easy – just remember the F words (Fat, Family history, Forty or Fifty). Fat because central overweight is associated with hyperglycaemia and the other cardiovascular risk factors. Family history because a first degree family member who has had diabetes, hypertension, dyslipidaemia or a premature cardiovascular event implies a genetic risk. And forty or (even worse) fifty is where the curve for both diabetes and cardiovascular events curve sharply upwards.Pre-diabetes is the earliest indicator we have. In fact the clock starts ticking many years before abnormal physiology starts the clock ticking.Cardiovascular risk is clearly increased in association with pre-diabetes and microvascular complications start many years before the diagnosis of diabetes.To view Figure 2: The Type 2 Syndrome click hereAs noted it is easy to check the F words. One or more should prompt a check of blood glucose, blood pressure and blood fats. One or more abnormal results may put lifestyle on the agenda for someone who is getting fatter, less active and older. You might also put it on your medical agenda given the effective medical interventions that are now available.

Pre-diabetes = cardiovascular and diabetes risk

The definition of pre-diabetes is based on a study of UK bureaucrats who had an OGTT and were followed up. The diagnostic criteria for IGT are based on the threshold where future cardiovascular events increased above baseline. Impaired fasting glucose (IFG) indicates a lesser but still significantly increased risk.The message of pre-diabetes (IFG /IGT) is that this person has one cardiovascular risk factor and is likely to have others. After all diabetes keeps bad company – hypertension, dyslipidaemia and thrombogenesis.The other message is that pre-diabetes indicates a very high risk of diabetes. In the Diabetes Prevention Programme 30% of those with impaired glucose tolerance develop diabetes in three years2. Diagnosis of pre-diabetes should prompt the lifestyle measures that have been shown to slow progression to diabetes: eat less, walk more and follow-up to pick up progression to diabetes when and if it does occur. Remember that right now people with diabetes remain undiagnosed for many years and have lots of time to develop the complications that are present at diagnosis (50% have these complications)3. These could be prevented by early diagnosis and effective intervention.

Pre-diabetes – assess and intervene

The F words prompt a check of blood glucose. Pre-diabetes prompts a check of medical and lifestyle risk factors for cardiovascular events and diabetes. Medical and lifestyle risk factors prompt the interventions that have been shown to reduce the risk of cardiovascular events and progression to diabetes.Treating to target (table 1) reduces cardiovascular risk4 and eating less and walking more reduces the risk of diabetes from 1/3rd in the next three years to l/10th.Interventions effectively reduce cardiovascular and diabetes risk. For example, in a diabetes cohort, at higher risk but on the same continuum as pre-diabetes, cardiovascular risk factor control can reduce the risk of cardiovascular events by 75%5. Lifestyle change can reduce the risk of progression from pre-diabetes to diabetes by 67%2. It is worth assessing risk you can change outcomes.To view Table 1: Targets fpr Type 2 Syndrome click hereSummaryLook for the F words.Assess medical and lifestyle risk factors.Intervene and change cardiovascular and diabetes risk.Pre-diabetes challenges you every day. Take the opportunity to improve outcomes for your patients.

References

1. Tapp RJ, Zimmet PZ, Harper CA, de Courten MP, Balkau B, McCarty DJ, Taylor, HR,Welborn TA, Shaw JE; Australian Diabetes Obesity and Lifestyle Study Group. 2001. 2. Diabetes in the Diabetes Prevention Program: Effects on Lifestyle Intervention and MetforminDiabetes. 2005 Aug;54(8):2404-24143. Phillips PDiabetes – a problem in every practiceCurrent Therapeutics 2001;42(Suppl 13):6-11)4. Dr Peter Harris, Dr Beres Joyner, Dr Pat Phillips, Carole Webster.Diabetes Management in General Practice 11th edition 2005/06 Diabetes Australia and The Royal Australian College of General Practitioners. 5. Patrick Phillips, Jody BraddonThe type 2 tablet. Evidence based medication for type 2 diabetes.Australian Family Physician. 2003; (6). (32)(6) 431-436