The Burden of Prediabetes

Prevalence

Prediabetes is a condition defined by the presence of impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) that has not yet reached the threshold for type 2 diabetes mellitus (T2D); the metabolic syndrome is also considered a prediabetes equivalent (1,2). Prediabetes raises short-term absolute risk of T2D by 3- to 10-fold (2). In the United States, 86 million people, or 37% of the US population, have prediabetes, and it is estimated that up to 70% of people with prediabetes may develop T2D during their lifetimes (3,4).

Screening and Monitoring of Prediabetes

Screening for Prediabetes

AACE recommends that individuals who meet any of the clinical risk criteria noted below should be screened for prediabetes or type 2 diabetes (T2D) (1).

Common Comorbidities and Complications of Prediabetes

Obesity
Obesity is a neuroendocrine disease that is itself associated with numerous metabolic and biomechanical complications. It is generally defined as a body mass index (BMI) ≥30 kg/m2, especially in the presence of obesity-related complications. In the context of prediabetes, obesity (1-3):

Management of Prediabetes

The primary goal of prediabetes management is to normalize glucose levels and prevent or delay progression to diabetes and associated microvascular complications.

The Burden of Type 1 Diabetes

Epidemiology

Overall, type 1 diabetes (T1D) accounts for approximately 5% of diabetes and affects about 20 million individuals worldwide. Among those younger than 20 years of age, T1D accounts for the majority of T1D cases (1,2). The current U.S. prevalence estimate of 1-3 million T1D patients may triple by 2050 due to a rising incidence of T1D (3).

Type 1 Diabetes Pathophysiology

Type 1 diabetes (T1D) is a chronic autoimmune disorder that occurs in genetically susceptible individuals and that may be precipitated by environmental factors. In a susceptible individual, the immune system is triggered to develop an autoimmune response against altered pancreatic beta cell antigens, or molecules in beta cells that resemble a viral protein. Approximately 85% of T1D patients have circulating islet cell antibodies, and the majority of patients also have detectable anti-insulin antibodies.

Type 1 Diabetes Diagnosis

Patients with type 1 diabetes (T1D) require exogenous insulin for survival and should be identified as soon as possible to avoid high morbidity due to a delay in insulin treatment.

Treatment of Type 1 Diabetes

Goals

The treatment goals for patients with type 1 diabetes (T1D) are the same as those for patients with type 2 diabetes (T2D), as outlined in Table 1 (1).

Table 1. Glucose goals for patients with diabetes (1).

A1C

Individualize on the basis of age, comorbidities, duration of disease*

The Burden of Diabetes

Epidemiology

Diabetes affects 9.4% of the population of the United States, or approximately 30.3 million people. Of these, 7.2 million have not been diagnosed. Approximately 90% of all diabetes cases are type 2 diabetes.1

Clinical Presentation of Type 2 Diabetes Mellitus

Risk Factors

The risk factors for the development of both prediabetes and type 2 diabetes mellitus (T2DM) are as follows:1

Diagnosis of Type 2 Diabetes Mellitus

There is a continuum of risk for poor patient outcomes as glucose tolerance progresses from normal to overt type 2 diabetes. AACE-defined glucose tolerance categories are listed in Table 1.1

Table 1. Glucose Testing and Interpretation1

Normal

High Risk for Diabetes

Diabetes

FPG < 100 mg/dL

IFG
FPG ≥100-125 mg/dL

Type 2 Diabetes Glucose Management Goals

Optimal management of type 2 diabetes requires treatment of the “ABCs” of diabetes: A1C, blood pressure, and cholesterol (ie, dyslipidemia). This web page provides the rationale and targets for glucose management; AACE guidelines for blood pressure and lipid control are summarized in Management of Common Comorbidities of Diabetes.

Glucose Targets

Glycemic Management in Type 2 Diabetes

The Comprehensive Care Plan

Every patient with documented type 2 diabetes (T2D) should have a comprehensive care plan (CCP), which takes into account the patient’s unique medical history, behaviors and risk factors, ethnocultural background, and environment. The ultimate goal of the CCP is to reduce the risk of diabetes complications without jeopardizing patient safety. To achieve this goal, the CCP should include the following components:1

Management of Common Comorbidities of Diabetes

As may be expected with a chronic disease that primarily affects middle-aged and older individuals, type 2 diabetes is usually complicated by other medical conditions. In the 1999-2004 cohort of the National Health and Nutrition Examination Survey (NHANES), only 14% of patients with type 2 diabetes had no other comorbidities.1 Here we briefly outline management recommendations for major comorbidities of patients diagnosed with diabetes—the management recommendations are the same whether patients have type 1 or type 2 diabetes mellitus (T1DM and T2DM).

Diabetes and Cancer

Epidemiologic data have demonstrated significant increases of various cancers in people with obesity and diabetes. Recently, concern has emerged that antihyperglycemic medications may also be associated with an increased prevalence of multiple cancers; however, available data are limited and conflicting.1,2

Team Approach to Type 2 Diabetes Management

Comprehensive care of patients with diabetes requires a team of healthcare professionals. Working with different healthcare providers allows the patient to learn in-depth information regarding their health and well-being. It also ensures that the patient’s needs are cared for and addressed. It is important to use other providers’ skills and specialties to ensure patients have the best care and understanding of their condition. Often, problems may be apparent to one healthcare provider, but go unnoticed by another.

Identification, Screening, and Diagnosis of Diabetes in Pregnancy

Management of Pregnancy Complicated by Diabetes

Preconception Care

AACE guidelines specify that preconception care is important for all women with preexisting type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) or previous gestational diabetes mellitus (GDM). One of the primary goals of preconception care is to educate patients about strategies to maintain adequate nutrition and glu­cose control before conception, during pregnancy, and in the postpartum period.1

The Burden of Prediabetes

Prevalence

Prediabetes is a condition defined by the presence of impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) that has not yet reached the threshold for type 2 diabetes mellitus (T2D); the metabolic syndrome is also considered a prediabetes equivalent (1,2). Prediabetes raises short-term absolute risk of T2D by 3- to 10-fold (2). In the United States, 86 million people, or 37% of the US population, have prediabetes, and it is estimated that up to 70% of people with prediabetes may develop T2D during their lifetimes (3,4).

Screening and Monitoring of Prediabetes

AACE recommends that individuals who meet any of the clinical risk criteria noted below should be screened for prediabetes or type 2 diabetes (T2D)1.

Common Comorbidities and Complications of Prediabetes

Obesity 
Obesity is a neuroendocrine disease that is itself associated with numerous metabolic and biomechanical complications. It is generally defined as a body mass index (BMI) ≥30 kg/m2, especially in the presence of obesity-related complications. In the context of prediabetes, obesity (1-3):

Management of Prediabetes

Treatment Goals 
The primary goal of prediabetes management is to normalize glucose levels and prevent or delay progression to diabetes and associated microvascular complications (1,2). Management of common prediabetes comorbidities such as obesity, hypertension, dyslipidemia, cardiovascular disease, and chronic kidney disease is also essential.

The Burden of Diabetes

Epidemiology

Diabetes affects 9.4% of the population of the United States, or approximately 30.3 million people. Of these, 7.2 million have not been diagnosed. Approximately 90% of all diabetes cases are type 2 diabetes.1

Type 1 Diabetes Pathophysiology

Type 1 diabetes (T1D) is a chronic autoimmune disorder that occurs in genetically susceptible individuals and that may be precipitated by environmental factors. In a susceptible individual, the immune system is triggered to develop an autoimmune response against altered pancreatic beta cell antigens, or molecules in beta cells that resemble a viral protein. Approximately 85% of T1D patients have circulating islet cell antibodies, and the majority of patients also have detectable anti-insulin antibodies.

Type 1 Diabetes Diagnosis

Patients with type 1 diabetes (T1D) require exogenous insulin for survival and should be identified as soon as possible to avoid high morbidity due to a delay in insulin treatment.

Treatment of Type 1 Diabetes

Goals

  • Utilize intensive therapy aimed at near-normal BG and A1C levels
  • Prevent diabetic ketoacidosis and severe hypoglycemia
  • Achieve the highest quality of life compatible with the daily demands of diabetes management
  • In children, achieve normal growth and physical development and psychological maturation
  • Establish realistic goals adapted to each individual’s circumstances

Clinical Presentation of Type 2 Diabetes Mellitus

Risk Factors

The risk factors for the development of both prediabetes and type 2 diabetes mellitus (T2DM) are as follows:1

Diagnosis of Type 2 Diabetes Mellitus

There is a continuum of risk for poor patient outcomes as glucose tolerance progresses from normal to overt type 2 diabetes.

Type 2 Diabetes Glucose Management Goals

Optimal management of type 2 diabetes requires treatment of the “ABCs” of diabetes: A1C, blood pressure, and cholesterol (ie, dyslipidemia). This web page provides the rationale and targets for glucose management; AACE guidelines for blood pressure and lipid control are summarized in Management of Common Comorbidities of Diabetes.

Glycemic Management in Type 2 Diabetes

The Comprehensive Care Plan

Every patient with documented type 2 diabetes (T2D) should have a comprehensive care plan (CCP), which takes into account the patient’s unique medical history, behaviors and risk factors, ethnocultural background, and environment. The ultimate goal of the CCP is to reduce the risk of diabetes complications without jeopardizing patient safety. To achieve this goal, the CCP should include the following components:1

Management of Common Co-morbidities of Diabetes

As may be expected with a chronic disease that primarily affects middle-aged and older individuals, type 2 diabetes is usually complicated by other medical conditions. In the 1999-2004 cohort of the National Health and Nutrition Examination Survey (NHANES), only 14% of patients with type 2 diabetes had no other comorbidities.1Here we briefly outline management recommendations for major comorbidities of patients diagnosed with diabetes—the management recommendations are the same whether patients have type 1 or type 2 diabetes mellitus (T1DM and T2DM).

Diabetes and Cancer

Epidemiologic data have demonstrated significant increases of various cancers in people with obesity and diabetes. Recently, concern has emerged that antihyperglycemic medications may also be associated with an increased prevalence of multiple cancers; however, available data are limited and conflicting.1,2

Team Approach to Type 2 Diabetes Management

Comprehensive care of patients with diabetes requires a team of healthcare professionals. Working with different healthcare providers allows the patient to learn in-depth information regarding their health and well-being. It also ensures that the patient’s needs are cared for and addressed. It is important to use other providers’ skills and specialties to ensure patients have the best care and understanding of their condition. Often, problems may be apparent to one healthcare provider, but go unnoticed by another.

The Burden of Diabetes in Pregnancy

Epidemiology

Three types of diabetes may complicate pregnancy: preexisting type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM), or gestational diabetes mellitus (GDM). By definition, the first two types of diabetes are already established prior to pregnancy. GDM, also referred to as hyperglycemia in pregnancy, is a condition in which glucose intolerance develops in a patient who has not been previously diagnosed with diabetes.1,2

Identification, Screening, and Diagnosis of Diabetes in Pregnancy

GDM Definition, Etiology, Risk Factors, and Pathophysiology

Definition

Gestational diabetes mellitus (GDM) has been defined as any degree of carbohydrate intolerance with onset during pregnancy. This definition is a misnomer in that it includes unrecognized overt diabetes that may have been present prior to pregnancy as well as hyperglycemia that develops during pregnancy. Preexisting type 2 diabetes can often present as severe hyperglycemia during pregnancy.

Management of Pregnancy Complicated by Diabetes

Preconception Care

AACE guidelines specify that preconception care is important for all women with preexisting type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) or previous gestational diabetes mellitus (GDM). One of the primary goals of preconception care is to educate patients about strategies to maintain adequate nutrition and glu­cose control before conception, during pregnancy, and in the postpartum period.1