If you’ve been recently diagnosed with prediabetes or type 2 diabetes or know people with diabetes symptoms, you aren't alone. There are now more than 29 million people (about one in 9) in the U.S. with diabetes and over 300 million people with diabetes worldwide. Unfortunately, the numbers keep going up! 

As rates of overweight and obesity rises, so goes prediabetes and type 2 diabetes. Yes, we have an epidemic of both on our hands. The rise of prediabetes and diabetes in the U.S. and worldwide are due in part to:

• large increase in numbers of adults and children who are overweight
• people are sedentary - not active
• the population is aging and people who are older are more glucose intolerant
• the number of people from ethnic groups with a high incidence of diabetes symptoms is growing in the US (African American, Hispanic American, Native American/American Indian, Asian Americans and Pacific Islanders)

You may wonder why doesn’t everyone who is overweight get prediabetes or type 2 diabetes? The answer: While being overweight or obese causes the body’s cells to be resistant to the effects of insulin, but insulin resistance alone isn’t enough to cause glucose levels to rise. What the research shows us is that developing prediabetes takes a combination of insulin resistance and a relative deficiency of insulin being made by the body. The amount of insulin a person’s pancreas can make is very much influenced by their genes. 

Yes, there’s definitely a genetic factor here. People who inherit genes linked to type 2 diabetes and are also carry around extra pounds may eventually not be able to keep making the larger amounts of insulin they need to overcome their insulin resistance. People who are overweight but don’t have these genes seem to be able to keep their insulin production up at least for the time being. 

Today 7 percent of pregnant women develop gestational diabetes. According to CDC, this number is escalating. That’s in part because more women are overweight and/or older when they get pregnant. Research also shows that over half of women diagnosed with diabetes during pregnancy will develop type 2 diabetes within the next decade. Staggering stats!

Women who’ve had gestational diabetes are encouraged to take the following actions to prevent prediabetes and type 2 diabetes. 

• About 6 to 12 weeks after pregnancy, at an after pregnancy visit with a healthcare provider, American Diabetes Association and other organizations concur that women who’ve had gestational diabetes should have an oral glucose tolerance test (OGTT). An Oral Glucose Tolerance Test (OGTT) is when after an overnight (10 hour) fast the women has a sample of blood drawn for an initial blood glucose check. The woman then drinks 75 grams of glucose solution. Then they have blood drawn at 30 minutes, 1 hour and 2 hours after drinking the glucose solution (see results of the OGTT below). 
• Annually or at least every 3 years women should get a glucose or A1c test and be screened for diabetes. Learn more about how diabetes is diagnosed.

In addition, women who’ve had gestational diabetes and have been diagnosed with prediabetes or have strong risk factors for developing type 2 diabetes should talk to their healthcare provider about adding the blood glucose lowering medication metformin to decrease insulin resistance. Some research shows metformin was even more effective at reducing the incidence of type 2 diabetes in women at risk than in women who didn’t have gestational diabetes. Learn more about the use of metformin in prediabetes.

Results of the Oral Glucose Tolerance Test*

*These results don’t apply to pregnant women and gestational diabetes.
Reference American Diabetes Association, Standards of Medical Care for Diabetes – 2015 

Learn more about Gestational Diabetes and why it’s a warning flag for type 2 diabetes. Heed the caution flag and take a preemptive strike against prediabetes or type 2 diabetes. 

The US Food and Drug Administration (FDA) has not yet approved any blood glucose lowering medication for prediabetes. Several of the blood glucose lowering medications that are approved for use in people with type 2 diabetes have been used in diabetes prevention studies, including metformin in the Diabetes Prevention Program study. 

Healthcare providers can prescribe these medications, so-called “off label.” Due to the incidence of prediabetes and growing evidence for the effectiveness of metformin in concert with weight loss, healthy eating and physical activity to slow the progression of type 2, metformin is being prescribed more often for this purpose.  Metformin is generic, has been around a long time and has been well-studied. In addition to having a beneficial effect on insulin resistance some research points to the beneficial effects of metformin on lowering heart disease and some cancers. 

If you have prediabetes pose the question of whether you should take metformin to your healthcare provider. 

What the research shows is that once most people are diagnosed with prediabetes they’ve already lost somewhere in the range of 50 to 80 percent of their insulin-making capabilities. While some people who are diagnosed with prediabetes catch it very early and can lose and keep off a significant amount of weight can reverse prediabetes, most people aren’t able to to do. It’s hard work! The Diabetes Prevention Program (DPP) study (which became the Diabetes Prevention Program Outcomes Study (DPPOS)) showed that as the years progressed, fewer people where able to reverse their prediabetes. Read more about the DPP and DPPOS.

Research shows that people who have both elevated fasting glucose and A1c levels when they’re diagnosed with prediabetes are more likely to develop type 2 than people who have just one of these risk factors.

Research from the DPP study (after the intensive first three years) found 4 independent predictors of reversing prediabetes and returning blood glucose levels to normal. 

They were: 

1. glucose levels closer to normal when they entered the study (which means their higher than normal glucose levels were caught early)
2. younger age at diagnosis
3. greater ability to continue to make the insulin needed by the body
4. lost more weight

The American Diabetes Association (ADA) currently prefers the term remission, rather than the word cure. This is defined by ADA as achieving glucose levels below the diabetes range without taking any glucose lowering medications. Remission implies the strong possibility of a relapse if a person regains the lost weight and/or as aging ensues. So, even if prediabetes goes into remission, it can’t be erased from a person’s checklist of health concerns. Most experts agree if a person has had prediabetes or type 2 diabetes in their medical history that they get an A1c test once a year to keep abreast of their glucose status. 

Research from around the globe over the last twenty years shows that a 7 percent weight loss, healthier calorie-conscious eating and regular physical activity can reverse, halt, or slow the progression of type 2 diabetes. Of course, to continue to halt or slow the progression of prediabetes or progression to type 2 diabetes people need to keep as many of those pounds off as possible, eat healthfully and continue regular physical activity.  

The large study on prediabetes done in the US is called the Diabetes Prevention Program (DPP). The initial 3 years of the study (the treatment phase), showed that losing about 5 to 7 percent of body weight (from the person's starting body weight) and getting 150 minutes of physical activity (usually walking) a week (30 minutes 5 times a week), helped people slow the progression from prediabetes to type 2 diabetes quite successfully. Yes, research has time and again shown that taking actions to eat less fat, count calories and be more physically active can reverse or slow the progression from prediabetes to type 2 diabetes. Research also has shown that many people can be even more successful adding regular counseling and support to help them make and practice healthier habits. You may want to consider working with a registered dietitian or other trained health professional to increase your likelihood for long term success with weight control and preventing type 2 diabetes.

Participants in the lifestyle change group did better than people who didn’t get this counseling but did take the glucose lowering medication metformin. (Learn more about whether people with prediabetes should take metformin. People in this group reduced progression to type 2 diabetes by about 30 percent versus those who received no treatment (control group). 

After following most of the participants in the DPP in the continuing study, the DPP Outcomes Study(DPPOS), at 10 years, those in the original lifestyle change group continued to reduce their progression to type 2 diabetes the most—about 35 percent—and those in the initial metformin group about 20 percent versus standard care. Recently, 15 year data from DPPOS showed continued reduction in the incidence of type 2 diabetes. The original lifestyle group had a 27 percent greater reduction and the metformin group a 17 percent reduced incidence versus standard care. 

Learn more details of the DPP and DPPOS at the point when the 10 year data were published here:  Prevent/Delay Diabetes? With a Bit of Weight Loss Concludes 10 Year NIH Study.

The actions you need to take to halt or slow the progression of prediabetes and also to slow the progression of type 2 diabetes are: 

Lose about 5 to 7 percent of your body weight and keeping those pounds off

Eat healthfully. Focus on vegetables, fruits, whole grains, legumes, low fat dairy foods and lighten up higher in fat protein foods and unhealthy fats and oils

Be physically active at least 150 minutes per week

Take a blood glucose lowering and other medications, such as lipid lowering and blood pressure medications, if they’re recommended to control and keep your glucose, lipids and blood pressure under control. Learn more about these targets here.

My book Diabetes Meal Planning Made Easy can help you make the type of step by step changes people did in the diabetes prevention studies around the goal to eat healthier and trim off a few pounds.

The diagnosis of prediabetes can be done with a blood glucose test (blood from a vein, not a finger stick) or by getting an A1C blood test (read below to learn more about the A1C test). If you suspect you may have prediabetes because you have one or more of the risk factors, a good first step is to take the American Diabetes Association risk test. Access this test and learn more about diabetes by reading this blog:  Diabetes Alert Day 2015: At Risk? Take Action Now!

Blood Glucose and A1C Numbers Used to Diagnose Diabetes and Prediabetes (see notes below)

Notes: These numbers do not apply to pregnant women and for the diagnosis of gestational diabetes. If the results from one test are not convincingly indicative of the diagnosis, then a repeat test should be done on a different day. 

*Hemoglobin A1C is a measure of blood glucose control over the past 2 to 3 months. Think of the A1C blood test as a video recording of all the ups and downs of blood glucose during that time. Since 2010 the American Diabetes Association and other diabetes organizations around the globe consider the A1C test the preferred measure to diagnose diabetes because it provides a better picture of glucose ups and downs over time. A1C is also used to monitor how diabetes is being managed.

Reference: American Diabetes Association, Standards of Medical Care for Diabetes – 2015. 

There are a number of risk factors for prediabetes and type 2 diabetes. Prediabetes will often progress to type 2 diabetes especially if a person with prediabetes doesn’t take early action. Read: Can prediabetes be reversed or slowed?

Risk Factors for Prediabetes and Type 2 Diabetes:

• Above 45 years old
• Family history of type 2 diabetes (parent, brother or sister)
• Member of an ethnic group with increased risk: African American,  Hispanic/Latino, Asian American or Pacific Islanders, American Indian or Alaska Native
• Diagnosed with gestational diabetes or given birth to a baby weighing more than 9 pounds
• Diagnosed with high blood pressure (hypertension)
• Live a sedentary lifestyle
• Overweight or obese (BMI > 25 or > 23 in Asian Americans)
• Smoke cigarettes
• Snore loudly, brief pauses in breathing during sleep, poor quality sleep and/or been told you have sleep apnea

Read more about prediabetes in my Washington Post Nutrition Q&A column from November 2013: I Have Prediabetes: What Should I Eat? 

According to the Centers for Disease Control and Prevention (CDC)  there are now 86 million Americans estimated to have prediabetes. Breaking this whooping number, down that’s 35 percent of adults over 20 years old and a mind-boggling 51 percent of adults over 65!  

Yet, according to the latest CDC estimate from 2013, only 11 percent of people with prediabetes know they have it. That’s unfortunate because you can’t do anything about something you don’t know you have. Get these and more diabetes facts from CDC here.

Good news! The number of people who are aware that they have prediabetes is ticking up. Hopefully as awareness efforts climb the number of diabetes prevention programs will continue to expand.  Learn more about the National Diabetes Prevention Programs.  

Learn more about prediabetes and how to reverse or slow down it’s progression in my book Diabetes Meal Planning Made Easy.

Today prediabetes is considered a diagnosis and a medical condition. It's when blood glucose (also called blood sugar) is higher than normal, but not high enough to be diagnosed as diabetes (see the numbers to diagnose diabetes below). Other names you may hear of for this condition are "impaired glucose tolerance" or "impaired fasting glucose". 

Two things are happening in the body when people develop prediabetes. 

• First, people slowly lose their insulin - making cells - beta cells. By the time type 2 diabetes is diagnosed people have often lost more than half of their beta cells. The body is working overtime to produce more and more insulin. When it can no longer produce enough insulin, blood glucose it rises into prediabetes ranges. 
• Second, people develop a relative insulin deficiency - a lot of insulin is produced but there's not enough insulin being made to cover the needs. Also, people typically develop insulin resistance—when the body's cells aren't able to use the insulin it makes. The body is essentially insensitive, or resistant, to the insulin the body does make. Learn more in Insulin Resistance, Weight Gain and Type 2 Diabetes: Connect the Dots. 

Blood Glucose and A1C Numbers Used to Diagnose Diabetes and Prediabetes (see notes below)

Notes: These numbers do not apply to pregnant women and for the diagnosis of gestational diabetes. If the results from one test are not convincingly indicative of the diagnosis, then a repeat test should be done on a different day. 

*Hemoglobin A1C is a measure of blood glucose control over the past 2 to 3 months. Think of the A1C blood test as a video recording of all the ups and downs of blood glucose during that time. Since 2010 the American Diabetes Association and other diabetes organizations around the globe consider the A1C test the preferred measure to diagnose diabetes because it provides a better picture of glucose ups and downs over time. A1C is also used to monitor how diabetes is being managed.

Reference: American Diabetes Association, Standards of Medical Care for Diabetes – 2015. 

Learn more about what happens when a person develops prediabetes and how to reverse or slow down it’s progression in my book Diabetes Meal Planning Made Easy.

If you have prediabetes: TAKE ACTION NOW! The earlier you take action the more likely it will be that you can reverse it or slow the progression to type 2 diabetes.