Borderline Diabetes

by Dr Rahul Baxi
I saw a patient recently with a fasting glucose of 210 mg% and a postmeal glucose of 325 mg% 
Me: Sir, since how many years you have diabetes?
Patient: I had ‘borderline diabetes’ since five years. I was not on any medicines, only some diet changes. I don’t know how it went so high now. 
Me: Did you check your glucose levels in the past five years? 
Patient: No. 
What is this ‘borderline diabetes’? 
Medical term for so called ‘borderline diabetes’ is “Prediabetes”. 
Prediabetes is a term used for individuals whose glucose levels do not meet the criteria for diabetes yet have abnormal carbohydrate metabolism. 
According to a study, the estimated prevalence of Prediabetes in India is 14% and that’s just those who have been tested. These are staggering figures. There are no symptoms ( prediabetes is asymptomatic) so many may have prediabetes but do not realise unless they check for it. Prediabetes is a risk factor for progression to diabetes and cardiovascular disease. It may be associated with obesity, deranged cholesterol levels and hypertension (high blood pressure). 
Criteria defining Prediabetes 
Impaired fasting glucose (IFG) – FPG 100-125 mg% 
Impaired Glucose Tolerance (IGT)- 2 hr PG during 75 gm OGTT 140-199 mg% 
HbA1c 5.7 to 6.4 % 
(FPG- Fasting Plasma Glucose, 2 hr PG- 2 hr Plasma Glucose, OGTT- oral glucose tolerance test) 
*For all three tests, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at the higher end of the range.
Who should get tested for Prediabetes? 
One can use this assessment tool online by ADA (in the end, click view results online) 
Diagnosed with Prediabetes. What next? 
If you have been diagnosed with prediabetes, you are at higher risk of CVD (cardiovascular disease), heart failure and stroke. Also, you have a high risk of getting diabetes, unless you make significant lifestyle changes. 
You need to check glucose levels at least once a year. 
There are effective interventions that prevent progression from Prediabetes to Diabetes. 
Toolkit for Diabetes prevention:
  1. An intensive lifestyle behaviour change program to achieve and maintain 7% loss of initial body weight and increase moderate intensity physical activity (such as brisk walking) to at least 150 min/week. 
  2. Appropriate dietary modification preferably under the guidance of a qualified Dietitian should be considered. Portion control, reducing sugar intake, increasing fibre rich foods in diet and having a diet low in carbohydrates and rich in proteins are important.
  3. Evidence suggests that overall quality of food consumed with an emphasis on whole grains, legumes, nuts, fruits and vegetables and minimal refined and processed foods is associated with lower risk of type 2 Diabetes 
  4. Lifestyle behaviour modification programs for diabetes prevention are cost effective. 
  5. No pharmacologic agent has been approved by the US FDA specifically for diabetes prevention. A drug called Metformin has some evidence and long term safety for diabetes prevention, though risk vs. benefit must be considered for each case.
  6. Inadequate sleep can interfere with insulin function. There is an association between sleep quality and prediabetes. A study recommends 8 hours of sleep each night to reduce the risk. 
So, if you get a fasting glucose tested, normal is upto 99 mg% or below. 100-125 mg% is impaired fasting glucose and 126 mg% or above is diabetes. Similarly, for 2 hr post meal (post 75 gm glucose test), normal is upto 139 mg%, impaired glucose tolerance if between 140-199 mg%, and diabetes if above 200 mg%. Similarly, HbA1c levels of 5.7 to 6.4% will define prediabtes in a patient, and 6.5% or above is diabetes. Similar to glucose measurements, the continuum of risk is curvilinear, so as A1C rises, the diabetes risk rises disproportionately. 
American Diabetes Association Professional Practice Committee; 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2022Diabetes Care 1 January 2022; 45 (Supplement_1): S17–S38.
American Diabetes Association Professional Practice Committee; 3. Prevention or Delay of Type 2 Diabetes and Associated Comorbidities: Standards of Medical Care in Diabetes—2022. Diabetes Care 1 January 2022; 45 (Supplement_1): S39–S45.
Dr Rahul Baxi is a Consultant Diabetologist working at Bombay Hospital, Mumbai. He completed his MD (Medicine) from Nagpur University in 2008. He has worked as Assistant Professor (Medicine) in Nair Hospital and TN Medical College, Mumbai and then as a Post Doctoral Fellow in Diabetes in CMC, Vellore. Having worked in Alexandra Hospital and NTFGH (NUH) Singapore for seven years, he joined Bombay Hospital in 2019. He has keen interest in management and prevention of Diabetes.” 
You can connect with him on twitter @baxirahul 

January 30, 2022

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