Prediabetes: It’s Never Too Early to Connect the Dots, with Gregory Weiss, MD

Gregory Weiss, MD

Diabetes remains one of the most significant health problems in the world. Substantial effort has been made to catch diabetes early and adhere to evidence-based practice in an effort to decrease the incidence of the disease and prevent a myriad of diabetes-related complications. Despite our best efforts as clinicians, the incidence of diabetes in the United States of America has not declined since 2000.¹

A prediabetic state has been recognized by the Centers for Disease Control and Prevention largely in an effort to intervene before clinical type 2 diabetes has developed. The goal of early recognition of those at risk for type 2 diabetes is to promote a healthy lifestyle through diet, exercise, and weight loss in the hopes of preventing or delaying clinical diabetes and the cardiovascular consequences of elevated blood glucose levels.

Eva Tseng, MD, MPH, assistant professor of medicine at Johns Hopkins, and colleagues recognized the disconnect between prediabetes screening by primary care providers and referrals to nutritionists and endocrinology specialists. As such, Tseng sought to examine the clinical care of prediabetic patients by primary care providers while determining what patient factors influence that care.² The authors further hoped to understand why the rates of clinical type 2 diabetes have not gone down. Their results were published in the March 2nd edition of the Journal of General Internal Medicine.

The authors examined a large cohort of patients who met laboratory criteria for prediabetes defined as a Hemoglobin A1C between 5.7% and 6.4%.² Tseng was surprised to find that only 13% of visits to primary care providers in this cohort were coded with prediabetes as a diagnosis.² Only two-thirds of these patients were ordered follow-up glycemic testing.² Only 1% of prediabetic patients were referred to a nutritionist and 5.4% started on metformin as treatment.2 Over the twelve months following entry into the cohort, 6% of subjects progressed to type 2 diabetes.²

A disconnect clearly exists between initial laboratory studies and interventions that may in many cases be lifesaving in the long term.

“Our results show that we have considerable room to improve in the identification and care of people with prediabetes within our health system and likely in many other places across the United States,” Tseng noted. ²

One sliver of good news is that, even though few prediabetic patients were coded as such, the ones that were and received referrals, saw a nutritionist and were prescribed metformin the twelve months after entering the cohort.² While higher risk patients like those with high body mass indices, and higher glucose levels were more likely to be recognized and referred, they were also more likely to progress to type 2 diabetes in the subsequent year.2

Tseng believes that these results present an opportunity for more aggressive recognition of prediabetes and prompt intervention.² Patients should be armed with information that may change the course of their health dramatically. This can only occur when prediabetes is recognized, and patients are informed of the basic steps they can take to prevent progression to type 2 diabetes. While medical interventions like metformin therapy can slow the progression to clinical diabetes, patients can do a lot on their own with the right guidance. Even low levels of exercise and small changes in diet can help slow or prevent worsening blood glucose levels and insulin resistance.

While these data are frustrating to clinicians and patients alike, they offer an opportunity to change. Complacency is the antithesis of progress. We cannot afford to be complacent where diabetes is concerned. The cardiovascular sequelae, loss of productivity, reduced quality of life, and costs associated with continued inaction are unacceptable.

The responsibility rests on us all but primary care providers, in particular, must recognize prediabetes, diagnose it, and make the appropriate referrals promptly. If appropriate, metformin should be started and regular laboratory screenings for blood glucose and HgbA1C performed. Those at higher risk should be followed closely and treated aggressively lest they progress to type 2 diabetes more quickly. With vigilance and persistence, we as clinicians can change the trajectory of our prediabetic patients and really make a difference in their lives.

References:

1. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. Atlanta, GA: Centers for Disease Control and Prevention; 2020.
2. Tseng, E., MD MPH, Durkin, N., BS, Clark, J. M., MD MPH, et al. Clinical care among individuals with prediabetes in primary care: a retrospective cohort study. J GEN INTERN MED (2022). https://doi.org/10.1007/s11606-022-07412-9