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Pre-diabetes: A new challenge and an opportunity for you

A new term, 'pre-diabetes' is being introduced to the Australian public by Diabetes Australia.

What is pre-diabetes and how will it affect your practice and your patients?

Diabetes Australia asked leading Endocrinologist, Dr. Pat Phillips of Queen Elizabeth Hospital in Adelaide, for an explanation of the diagnostic criteria and the call to action.

Pre-diabetes:
• Affects one in six adults and is also present in children/adolescents.
• Is part of the insulin resistance syndrome comprising obesity, abnormal blood glucose levels, hypertension, dyslipidaemia and thrombogenesis.
• Is a marker of increased risk of future cardiovascular events and Type 2 diabetes.
• Should prompt review of lifestyle and medical risk factors and interventions to reduce future problems.

'Australians are world champions coming in first, second and third. First: Olympic Nation; Second: Fattest Developed Nation (US wins); and Third: Least active nation (UK wins). Coming first is good news', says Dr Phillips. 'Runners-up are losers', he said.

At present, overweight/obese Australians outnumber and greatly outweigh healthy-weight Australians (source: 1). Associated with or causative of this overweight/obesity, 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,' said Dr Phillips.

Included in the literature being sent to surgeries is an innovative and interactive card that patients can use to assess their risk of pre-diabetes.

The risk factors are a family history of:
• Diabetes,
• Age,
• Gestational Diabetes,
• Polycystic Ovarian Syndrome,
• Sedentary lifestyle,
• Overweight/obesity,
• Heart disease,
• Waist circumference and
• Ethnicity.

Dr Phillips says pre-diabetes is one of the earliest indicators we have of risk of Type 2 diabetes. 'In fact, the clock starts ticking many years before the diagnosis of diabetes.'

Pre-diabetes (IGT/IFG) = Cardiovascular and Type 2 diabetes risk. This is the important message of pre-diabetes.

'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 (impaired glucose tolerance) are based on the threshold where future cardiovascular events increased above baseline. IFG (Impaired Fasting Glucose) indicates a lesser but still significantly increased risk,' Dr Phillips said. Pre-diabetes is itself a risk factor for cardiovascular disease.

Dr Phillips said 'The message of pre-diabetes (IGT/IFG) 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.

'In the Diabetes Prevention Program, 30% of those with impaired glucose tolerance developed diabetes within three years' (2).

Pre-diabetes in adolescents
Paediatric Endocrinologist, at The Children's Hospital at Westmead in Sydney, Dr. Geoff Ambler, reports seeing increasing numbers of children from nine years and up, with features of pre-diabetes. 'These problems are no longer confined to the domain of adult medicine. They already have obesity and other physical signs of insulin resistance, such as acanthosis nigricans. Biochemical testing confirms that insulin resistance is present,' he said.

Dr Ambler says that although glucose tolerance may still be normal at this stage, these children have a high likelihood of developing Type 2 diabetes as teenagers or young adults, unless intervention is successful.

'Lifestyle factors such as inactivity and unhealthy eating are major factors in these children and their families, but sustained modification is not easy.'

Diagnosis of pre-diabetes

IFG is defined as a fasting blood glucose level of > 6.1mmol/L and <7.0mmol/L.

IGT is defined as a fasting blood glucose level of <7.0mmol/L and a 2-hour plasma glucose level of >7.8mmol/L and <11.1mmol/L following a 75g glucose load.

Early intervention programs through healthy eating and physical activity should be introduced to your patients. Dr Phillips said, 'diagnosis of pre-diabetes should prompt the lifestyle measures that have been shown to slow progression to diabetes'.

Retesting for those at risk of diabetes should be ordered annually, but there is no need for these patients to monitor their blood glucose levels on a day to day basis or for HbA1C tests to be ordered. Patients with the insulin resistance syndrome should be followed regularly and all cardiovascular risk factors should be managed. People with pre-diabetes are not eligible for the government sponsored National Diabetes Services Scheme.

Interventions
'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).'

According to Dr Phillips, early diagnosis and effective intervention could prevent these. He said, 'Lifestyle change can reduce the risk of progression from pre-diabetes to diabetes by 67% (2).Interventions effectively reduce cardiovascular and diabetes risk. For example, in a diabetes cohort at a higher risk but on the same continuum as pre-diabetes, cardiovascular risk factor control can reduce the risk of cardiovascular events by 75% (4).' Dr Phillips says that pre-diabetes challenges you every day. 'Take the opportunity to improve outcomes for your patients.'

Target: 2 million
Diabetes Australia is targeting an estimated two million people who are most at risk of pre-diabetes, as the follow-up to last year’s campaign which launched the catchy slogan, ‘Be Well Know Your BGL’. As in last year’s campaign, a television commercial and some four million print articles will be produced to help spread the message, that Type 2 diabetes may be prevented through early intervention and lifestyle changes.

To support the campaign, the charity is also providing a range of lifestyle and medical management advice on its website, which has been specially developed for GPs. You can download a diagnostic calculator tool or a chart of the latest Diabetes Diagnostic Guidelines for easy reference.

Diabetes Australia says the campaign urging Australians to ‘Be Well Know Your BGL’ is an ongoing and successful clarion call of awareness. A survey of new members after the launch last year, showed that 6% were diagnosed with Type 2 diabetes after following the advice of the campaign and speaking to their family doctor about diabetes.

The GP information packs
Alphapharm has again supported National Diabetes Week and the companies sales representative will deliver envelopes containing the support material. Surgeries they do not visit will receive the material by mail. For the first time, practice nurses have been brought into the campaign and are being invited to distribute the patient risk assessment cards.

References
1. The Australian Diabetes, Obesity & Lifestyle Study (AusDiab)
2. Diabetes Prevention Program ( DPP)
3. Diabetes a Problem in Every Practice
4. The Type 2 Tablet Figures