Prediabetes

There are no specific symptoms of prediabetes. That is why it often goes undetected until a serious health issue shows up. Indeed, people can have the condition for years before they see any symptoms of higher than normal (impaired) blood glucose levels.

One sign to look out for is a skin condition called acanthosis nigricans, in which there is an abnormal increase (darkening) in the colour of the skin along with velvet-like thickening, especially in the skin fold regions like the neck, groin and under the arms.

In the absence of clear symptoms, prediabetes may be detected in regular (annual or biannual) health check-ups, including basic tests like complete blood count (CBC). If you have a family history of diabetes, if you are overweight (BMI or 25 or more) or if you have high blood pressure (hypertension), if you smoke or chew tobacco, then it might be a good idea for you to talk to your doctor about the ideal frequency of health check-ups for you.

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There are some factors that may increase your risk of prediabetes and diabetes in life. These factors are -

• Diet: Diet rich in red and processed meat, carbonated drinks and sugar-sweetened beverages is often associated with a higher risk of prediabetes. 
• Bodyweight: The extra fatty tissue inside and between the muscle and skin around the abdomen makes the body cells more resistant to insulin. This makes an overweight person more prone to become prediabetic.
• Sedentary lifestyle: Indulging in any type of physical activity would help you manage your weight and use up sugar for energy. In an inactive person, the body is unable to use insulin effectively, thus they become susceptible to prediabetes.
• Hereditary: A person with a family history of type 2 diabetes would be at increased risk of developing prediabetes.
• Pregnancy diabetes: If you would have had diabetes during pregnancy (gestational diabetes), then you and your child are at higher risk of developing prediabetes.
• Polycystic ovary syndrome: Women with polycystic ovary syndrome may suffer from irregular menstrual periods and obesity which increases their risk of developing prediabetes.
• Hormonal disorders: Disorders such as Cushing’s syndrome and acromegaly occur due to defect in the body's growth hormones. These hormones affect blood sugar levels and make people prone to prediabetes.
• Sleep abnormalities: People with obstructive sleep apnea (repeatedly disrupted sleep) have an increased risk of insulin resistance in the body.
• Tobacco use: Smoking tobacco may increase insulin resistance in the body, making the person prone to prediabetes. The nicotine in chewing tobacco has also been linked to higher blood glucose and greater insulin resistance.
• Medications: Certain medicines such as glucocorticoids, antidepressants, and some drugs for HIV can lead to insulin resistance in the body.

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There are no exact causes of prediabetes but there are some factors—including obesity, family history, physical inactivity and others—which may contribute to prediabetes in a person as all these things promote insulin resistance in the body. Excess fat in the body has been associated with chronic inflammation which can result in health problems such as high blood pressure and heart disease.

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Prediabetes can be prevented by making small changes in lifestyle. Health goals such as losing weight, lowering blood pressure, improving cholesterol, and lowering the levels of triglycerides can be achieved by making changes in food habits and exercising regularly. Here are a few things you can do:

• Avoid eating oily snacks and sweets. You can replace them with vegetables like carrots or cucumbers or some fruits.
• Replace fat-rich meat in your diet with lean meat, skinless poultry, fish, egg whites, and beans.
• Avoid drinking caffeinated beverages such as coffee, soft drinks and energy drinks. Instead, have lemon water, plain tea or fruit juice.
• Consume whole grains such as wheat, corn, rice, oats, barley, quinoa and sorghum, instead of refined flours.
• Prefer olive oil for making food to butter and other cooking oils.

Exercises that can help prevent prediabetes:

• Practice moderate-intensity physical activity for at least 150 minutes per week or at least 30 minutes on most days of the week. You may practice moderate-intensity physical activities such as brisk walking, water aerobics, cycling, playing games like tennis, roller skating and gardening work.
• You can also indulge in vigorous-intensity physical activity for 75 minutes a week which could involve running, uphill bicycling, swimming and playing games like football or tennis.

Lifestyle changes that can help prevent prediabetes:

• Reduce stress by doing regular sessions of meditation or yoga as it can help in lowering inflammation in the body, thus slowing down the progression of insulin resistance.
• Get proper sleep of at least 7 to 8 hours, as sleep deprivation has been associated with increased insulin resistance.
• Quit smoking to keep your blood sugar levels healthy and balanced.

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In someone with prediabetes, blood glucose levels are higher than normal but lower than in diabetes. The tests that can help in diagnosing prediabetes are:

• Oral glucose tolerance test: In the oral glucose tolerance test (OGTT), you will be asked to consume about 75 grams of glucose—which is equivalent to the amount of sugar present in about two cans of cola—and then your blood sugar will be tested after an hour. If you have prediabetes, your blood would show impaired glucose tolerance.
• Fasting blood glucose test: You will be asked to stay off food and water for eight to 12 hours before the fasting blood glucose test. If you have prediabetes, your fasting glucose will be in the range of 100-125 milligrams per deciliter (0.1 litres) of blood.
• HbA1c test: In the HbA1c test, your blood samples will be taken at a random time of the day. This test measures the average blood sugar of the body for the past two to three months.

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There is no specific treatment for prediabetes, but you can prevent it from turning into diabetes by making some lifestyle changes such as maintaining a healthy weight, exercising daily and eating a healthy diet. These changes can not only control your blood sugar levels but also keep them from getting higher. 

People with prediabetes are also at a higher risk of getting heart disease, so they need to make lifestyle changes to control their blood pressure along with the levels of cholesterol and triglycerides.

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Prediabetes is not a disease in itself but an unhealthy state in which the person is more likely to develop diabetes than others.

The good news is that prediabetes is usually reversible, so some people can bring their blood sugar levels down to normal through strict diet control, exercise and stress reduction. According to the ICMR Guidelines for Management of Type 2 Diabetes 2018, studies show that prediabetes can be reversed in one-third of patients and where diet and exercise alone don't work, these may be paired with daily doses of diabetes drug metformin to keep blood sugar in check.

The bad news is that some of the damage to blood vessels and organs that occurs in diabetes can start early, during the prediabetic stage—that is why it is important to control high blood sugar as early as possible.

Another piece of bad news is that prediabetes seldom has any signs or symptoms; your best bet for catching it early is to go for routine check-ups, especially if you have a family history of diabetes, a condition which increases the risk of insulin resistance like polycystic ovary syndrome or if you are overweight or obese.

To be sure, some prediabetics may become diabetic despite making drastic lifestyle changes. Having said that, diet control, exercise and stress management would only help such people manage their diabetes so they too should adopt these changes for good.

Here's a look at the blood sugar levels in prediabetes:

Our blood sugar level is actually seen as falling within a range. Here's a look at how it is slotted into normal, prediabetic and diabetic ranges:

Fasting blood sugar:

Two hours after eating, or two hours post-prandial:

Source: American Diabetes Association or ADA

The World Health Organization has a slightly different range: the WHO defines prediabetes as blood sugar levels between 110 mg/dL and 125 mg/dL.

The 2018 ICMR guidelines for the management of type 2 diabetes—which takes into account both the ADA and WHO ranges—underlines two main features of prediabetes: impaired fasting glucose and impaired glucose tolerance.

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According to the Indian Council of Medical Research (ICMR) guidelines, screening for prediabetes should be done once every three years. In people who are prediabetic, blood sugar should be tested annually to check for progression to diabetes.

The HbA1c test—also known as the glycosylated or glycated hemoglobin test—is one of the tests done to diagnose prediabetes and diabetes and keep an eye on blood sugar levels. This test looks for the percentage of red blood cells linked to glucose—a higher number indicates more blood sugar.

According to the ICMR 2018 guidelines for type 2 diabetes: "Glycosylated (glycated) haemoglobin (HbA1c) is also recommended for screening; however, in India there are some limitations regarding its use."

According to the "Use of Glycated Haemoglobin (HbA1c) in the Diagnosis of Diabetes Mellitus: Abbreviated Report of a WHO Consultation", this test has some advantages as well as disadvantages:

Prediabetes Hb1Ac advantages:

• HbA1c helps to gauge blood sugar over the past two to three months rather than just the present.
• HbA1c doesn't require preparation such as fasting by the patient.

Prediabetes Hb1Ac disadvantages:

• According to the WHO report, the Hb1Ac is more expensive—it can be unaffordable for some in the low and middle-income countries according to the WHO.
• The WHO report also says this test is not as widely available as the blood glucose test.
• A severe illness that affects the red blood cells or any problems with the haemoglobin (haemoglobinopathy) can affect the test results, making them less accurate.

Prediabetes Hb1Ac range: A value of 5.7-6.4% on an Hb1Ac test indicates prediabetes whereas as 6.5% or more is considered diabetes.

Prediabetes Hb1Ac frequency of testing: Where this test is used for diabetics, the ICMR guidelines say it should be done every six to 12 months in diabetics with glycated haemoglobin less than 7% with medication and every three months if it is 7% or more.

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