Before the Pre. PREDIABETES Diagnosis, Management, Treatment. A few thoughts on diabetes.

Transcription

1 PREDIABETES Diagnosis, Management, Treatment Before the Pre A few thoughts on diabetes. James Lenhard, MD Director, Diabetes and Metabolic Diseases Center Christiana Care Health System JLenhard@ChristianaCare.org Number and Percentage of U.S. Population with Diagnosed Diabetes, Age-Adjusted Estimates of the Percentage of Adults (20 years old) with Diagnosed Diabetes From 1980 through 2010, the crude prevalence of diagnosed diabetes increased by 161%! From 2008 to 2010 there has been little change. CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at

2 Prevalence of Diabetes Number of Persons with Diagnosed Diabetes, United States, Prevalence of Diabetes Number of Persons with Diagnosed Diabetes, United States, Diabetes is becoming more common in the United States. In 2000, about 12 million persons in the United States reported that they had diabetes. As the detailed tables show, people aged 65 years or older account for almost 40% of the population with diabetes. Between 1996 and 1997 an unusually large increase occurred in the number of people with diagnosed diabetes. Most of this increase is likely due to changes in the survey used to measure diagnosed diabetes. Diabetes is becoming more common in the United States. In 2000, about 12 million persons in the United States reported that they had diabetes. As the detailed tables show, people aged 65 years or older account for almost 40% of the population with diabetes. Between 1996 and 1997 an unusually large increase occurred in the number of people with diagnosed diabetes. Most of this increase is likely due to changes in the survey used to measure diagnosed diabetes Estimates 17.9 million diagnosed 5.7 million undiagnosed 7.8% of our population 2011 Estimates 18.8 million diagnosed 7.0 million undiagnosed 8.3% of our population 23.6 million 25.8 million Pre-diabetes = 57 million! Pre-diabetes = 79 million! Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes Obesity (BMI 30 kg/m 2 ) No Data <14.0% % % % >26.0% Diabetes No Data <4.5% % % % >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at

3 Source: National Health and Nutrition Examination Survey. Source: National Health Interview Survey estimates projected to the year Rate of new cases of type 1 and type 2 diabetes among youth aged < 20 years, by race/ethnicity, < 13 years old years old Source: SEARCH for Diabetes in Youth Study NHW=non-Hispanic whites; NHB=non-Hispanic blacks; H=Hispanics; API=Asians/Pacific Islanders; AI=American Indians Changes in Diabetes Prevalence The CDC estimates that a child born in the year 2000 has a one in three chance of developing diabetes in their lifetime. If diabetes continues to increase by 8 % each year, it will double in the US every 12 1/2 years. Data from BRFSS Mokdad et al, JAMA 2003;289:76-79

4 Overall Hispanic African American Caucasian Lifetime Risk of Developing Diabetes for People Born in 2000 in the USA Age-Specific Percentage of Civilian, Noninstitutionalized Population with Diagnosed Diabetes, by Age, Race and Sex, United States, 2008 Female Male Female Male Female Male Female Male Source: cdc.gov Estimated Prevalence and Health Care Costs of Adults With Diabetes Prediabetes Undiagnosed Diabetes Type 1 Diabetes Type 2 Diabetes TOTAL Prevalence in Adult Population (est.) 2020 (est.) Health Costs Attributable to Diabetes (Billions) (est.) 2020 (est.) 26.3% 28.4% 36.8% $27 $34 $ % 3.1% 4.1% $12 $15 $ % 0.2% 0.2% $4 $5 $73 7.6% 8.2% 10.8% $110 $140 $2, % 39.9% 51.9% $153 $194 $3,351 Delaware - Percentage of Adults with Diagnosed Diabetes, Year Crude % Age Adjusted % Three-year averages were used to improve the precision of the annual estimates. The United States of Diabetes: Challenges and Opportunities in the Decade Ahead, United Health Group,

5 Deaths Diabetes Prevalence by County 2009 Age-Adjusted Estimates of the Percentage of Adults with Diagnosed Diabetes in Delaware State Kent New Castle Sussex % 10.9% 7.5% 9.3% % 6.6% 9.9% Delaware Percentage of Adults Reporting They Have Been Told They Have Diabetes 8.7% 8.0% DE USA 3 2 Source: Delaware Health and Social Services, Division of Public Health, Behavioral Risk Factor Survey (BRFS), and DE Diabetes Mortality Five Year Age Adjusted Mortality Rates Rank Leading Cause of Death Number Number 1) Diseases of heart ) Malignant neoplasms ) Cerebrovascular diseases ) Chronic lower respiratory diseases ) Accidents (unintentional injuries) 6) Diabetes mellitus ) Alzheimer's disease ) Nephritis, nephrotic syndrome & nephrosis ) Influenza & pneumonia ) Septicemia Five-Year Age-Adjusted Mortality Rates from Diabetes (Rates per 1000,000, adjusted to US 2000 Population) Delaware Diabetes Mortality Rates Year Delaware Kent County New Castle County Sussex County

6 0 25 Percentage of Adults Reporting They Have Been Told They Have Diabetes By Age Gestational Diabetes by Age DE vs. USA Gestational Diabetes Prevalence by Percentage % DE %USA % USA % DE 5 < Total Adult Behavioral Risk Factor Surveillance System Data 3.56 Total Age-Adjusted Estimates of the Percentage of Adults (20 years old) with Diagnosed Diabetes Prediabetes

7 47-year-old African American man, hasn t seen doctor in years Works as a truck driver, eats mostly fast food Smokes 1 pack per day At health fair found to have BP = 146/86, total cholesterol = 210 Weight = 230 lbs; BMI = 29 kg/m² Family history of HTN and diabetes Age 47 Race/ethnicity African American Gender Male Family history HTN and diabetes Overweight/obesity BMI = 29 Abnormal lipid metab TC = 210 Hypertension BP = 146/86 Smoking 1 pack per day Physical Inactivity Yes Unhealthy diet Fast food diet Diabetes?? Risk Factors for Diabetes Age 45 and older History of vascular disease Overweight (BMI 25) Signs of insulin resistance Hypertension (such as PCOS or Abnormal lipid levels acanthosis nigricans) Family history of diabetes Pre-diabetes Race/ethnicity Inactive lifestyle History of gestational diabetes American Diabetes Association. Diabetes Care 2012; 34;(Suppl.1):S Testing for Diabetes and Pre-Diabetes Consider testing if person is: Age 45 or older An overweight adult with another risk factor Obtain: A1C or FPG or 2-hour plasma glucose post 75-g oral glucose challenge Repeat testing every 3 years. Test sooner than age 45 or more often than every 3 years in a very high risk individual. American Diabetes Association. Diabetes Care 2012; 34;(Suppl.1):S11-61.

8 What is Pre-diabetes? Pre-diabetes is a medical condition where blood glucose is higher than normal but not high enough to be diagnosed as diabetes It increases the risk for type 2 diabetes and cardiovascular disease Most people have pre-diabetes before they develop type 2 diabetes American Diabetes Association. Diabetes Care 2012; 34;(Suppl.1):S Glucose (mg/dl) Natural Progression of Type 2 Diabetes Clinical Features DIAGNOSIS Post-prandial Glucose Insulin Level Inadequate Decreasing b-cell Function b-cell Function Obesity IGT Diabetes Fasting Glucose Insulin Demand Macrovascular changes Microvascular changes Uncontrolled hyperglycemia Relative Insulin Demand Years Source: Adapted from Type 2 Diabetes BASICS. Minneapolois, MN: International Diabetes Center;2000. Diagnostic Criteria for Pre-diabetes and Diabetes Category A1C Fasting Plasma Glucose Test (FPG) American Diabetes Association. Diabetes Care 2012; 34;(Suppl.1):S Hour Oral Glucose Challenge Acceptable < 5.7% Below 100 mg/dl Below 140 mg/dl Pre-diabetes 5.7% - 6.4% mg/dl (IFG) mg/dl (IGT) Diabetes 6.5% 126 mg/dl or above 200 mg/dl or above IFG = Impaired Fasting Glucose IGT = Impaired Glucose Tolerance IFG and IGT BOTH are Prediabetes Impaired Fasting Glucose (IFG): a condition in which the blood glucose level is between 100 mg/dl to 125mg/dL after an 8- to 12-hour fast. Impaired Glucose Tolerance (IGT): a condition in which the blood glucose level is between 140 and 199 mg/dl at 2 hours during an oral glucose tolerance test (OGTT).

9 What is Pre-diabetes? Most people with pre-diabetes develop type 2 diabetes within 10 years. Prediabetes progresses to diabetes at a rate of about 10% each year if nothing is done. People with pre-diabetes are identified by having a screening test which shows they have IFG, IGT or an A1C of 5.7% - 6.4% Progression to diabetes is NOT inevitable Diabetes and Prediabetes in America Prevalence IFG IGT Total Prediabetes Age > Age > Non-Hispanic white age > 20 Non-Hispanic black > age 20 Mexican American > age Total Diabetes and Prediabetes American Diabetes Association. Diabetes Care 2012; 34;(Suppl.1):S Data from NHANES Cowie CC et al, Diabetes Care 32:287, 2009 Almost 1 out of 4 Kids Have Diabetes or Prediabetes in America The study sample included 3383 participants aged 12 to 19 years from the 1999 through 2008 NHANES. From to the prevalence of prediabetes/diabetes increased from 9% to 23%. 37% of normal weight adolescents had at least one risk factor. A May, Prevalence of Cardiovascular Disease Risk Factors Among US Adolescents, Pediatrics Vol. 129 No. 6 June 1, 2012 pp doi: /peds ) Most People Are Not Aware That They Have It Their doctor may not be aware either. Percentages of U.S. Adults Who Have Ever Been Told They Have Prediabetes, by State, 2010 Alabama 7.0 Alaska 7.0 Arizona 6.2 Arkansas Percentage (%) NA California 8.0 Colorado 5.7 Connecticut 5.3 Delaware 6.1 District of Columbia 5.5 CDC.gov/diabetes

10 Almost 70% of patients with first MI have IGT or undiagnosed diabetes N = 181 consecutive patients admitted to CCU Where does IFG/IGT fit in the spectrum of hyperglycemia? Patients (%) Glucose tolerance test results Undiagnosed diabetes Impaired glucose tolerance (IGT) Norhammar A et al. Lancet. 2002;359: ATP Guidelines for Metabolic Syndrome Risk Factor Clinical Identification of the Metabolic Syndrome Defining Level Abdominal obesity Men >102 cm (> 40 inches) Women >88 cm (> 35 in) Triglycerides > 150 mg/dl High density lipoprotein Men < 40 mg/dl Women < 50 mg/dl Blood pressure > 130/85 mm Hg Fasting glucose > 100 mg/dl The Metabolic Syndrome 25 30% of all Americans! Most people with diabetes will die from a cardiac event like a myocardial infarction or a stroke. Executive Summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001; 285:

11 Cardiometabolic Risk Factors Overweight/obesity Source: CDC, ADA Desired Goals for Healthy Patients Prevention of overweight/obesity as measured by BMI (normal = ). In those who are overweight/obese, the goal is to lose 5 7% of body weight. Age Insulin Resistance Genetics? Overweight/ Obesity Abnormal Lipid Metabolism LDL ApoB HDL Trig Abnormal lipid metabolism High LDL cholesterol Low HDL cholesterol High triglycerides Source: NHLBI, ATP III Guidelines, ADA Hypertension Source: NHLBI, JNC7 Fasting blood glucose Desirable levels are less than 100 mg/dl. Desirable levels are greater than 40 mg/dl in men and greater than 50 mg/dl in women. Desirable levels are less than 150 mg/dl <140/90 mm/hg or 130/80 mm/hg for people with diabetes (Ideal is less than 120/80 mm/hg) Below 100 mg/dl Lipids BP Glucose Cardiometabolic Risk Global Diabetes / CVD Risk Age, Race, Gender, Family History Source: ADA Physical inactivity Source: CDC At least 30 minutes of moderate activity most days Smoking Source: ADA Children Source: ADA Quit or never start Maintain healthy weight for age, sex, and height. Smoking Physical Inactivity Unhealthy Eating Hypertension Inflammation Hypercoagulation UKPDS: Incidence Rate of MI per Hba1c % Stratton, I. M et al. BMJ 2000;321: Copyright 2000 BMJ Publishing Group Ltd.

12 Measure BMI routinely at each regular checkup. Classifications: BMI = normal BMI = overweight BMI = obesity BMI 40 = extreme obesity Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication # , September 1998, National Institutes of Health. THE DONKEY DIET Primary Metabolic Disturbance Overnutrition Intermediate Vascular Disease Risk Factor Insulin Resistance Hypertension Dyslipidemia Hyperglycemia Hyperinsulinemia Inflammation Impaired Fibrinolysis Endothelial Dysfunction Intravascular Pathology Atherosclerosis Coronary arteries Carotid arteries Cerebral arteries Aorta Peripheral arteries Hypercoagulability Despres JP, et al. Abdominal obesity and metabolic syndrome. Nature. 2006;444: Clinical Event CVD Lifestyle modification Reduce caloric intake by kcal/day (depending on starting weight) Target 1-2 pound/week weight loss Increase physical activity Healthy diet Diabetes Prevention Program DASH diet Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication # , September 1998, National Institutes of Health. Diabetes Prevention Program (DPP) Diabetes Care 25: , The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, NIH Publication No , August 2004

13 Consider pharmacologic treatment BMI > 30 with no related risk factors or diseases, or BMI > 27 with related risk factors or diseases As part of a comprehensive weight loss program including diet and physical activity Consider surgery BMI > 40 or BMI > 35 with comorbid conditions Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication # , September 1998, National Institutes of Health. Diabetes Prevention Program (DPP) Diabetes Care 25: , 2002 Desirable Less than 200 mg/dl Borderline high risk mg/dl High risk 240 mg/dl and over American Diabetes Association. Understanding Cardiometabolic Risk: Broadening Risk Assessment and Management, Dyslipidemia Richard M Bergenstal, MD International Diabetes Center

14 Increased: Triglycerides VLDL LDL and small dense LDL ApoB Decreased: HDL Apo A-I Cigarette smoking Hypertension ( 140/90 mm Hg or on antihypertensive medication) Low HDL-C (<40 mg/dl) Family history of early heart disease Age (men 45 years; women 55 years) American Diabetes Association. Diabetes Care. 2007;30:S4-41. Statins (also called HMG-CoA reductase inhibitors) work by increasing hepatic LDL-C removal from the blood. Recommended for ALL people with diabetes > age 40 unless their TC is < 135 or there is a contraindication. Resins (also called bile acid sequestrants) bind to bile acids in the intestines and prevent their reabsorption, leading to increased hepatic LDL-C removal from the blood. Cholesterol absorption inhibitors help lower LDL-C by reducing the amount of cholesterol absorbed in the intestines; increases LDL receptor activity For patients >20 years of age, cholesterol should be checked every 5 years Ordering a fasting lipid panel is preferred to gauge the patient s total cholesterol, LDL-C, HDL-C and triglycerides Treatment priorities

15 Relative Risk LDL-C-lowering Category of risk LDL-C Goal 0-1 risk factor* < 160 mg/dl or lower Multiple (2+) risk factors* People with coronary heart disease or risk equivalent (e.g., diabetes or prediabetes) Known CAD and DM < 130 mg/dl or lower < 100 mg/dl or lower < 70 mg/dl or lower may be ideal Improve glucose control if diabetes is present Weight loss if overweight Daily exercise Smoking cessation Dietary modifications including low saturated fat (fat intake less than 30% of total calories and saturated fat less than 7% of total calories), low cholesterol (no more than 200 mg daily) diet Pharmacologic treatment frequently necessary Risk factors include hypertension; HDL < 40; family history of MI before age 55; male > 45 years old; female > 55 years old; smoking. 3 Men Women N = 5, Triglyceride Level, mg/dl Castelli WP. Epidemiology of triglycerides: a view from Framingham American Journal of Cardiology. 1992;70:3H-9H. Persons without Diabetes Test at least every 5 years, starting at age 20, including adults with low-risk values Persons with Diabetes In adults, test at least annually Lipoproteins: measure at after initial blood glucose control is achieved as hyperglycemia may alter results Preventing Cancer, Cardiovascular Disease, and Diabetes: A Common Agenda for The American Cancer Society, the American Diabetes Association, and the American Heart Association. Circulation. 2004;109: American Diabetes Association. Standards of Medical Care in Diabetes Available at:

16 Hypertension Guidelines Improve glucose control if diabetes is present Weight loss if overweight Daily exercise Smoking cessation Dietary modifications including low saturated fat (fat intake less than 30% of total calories and saturated fat less than 7% of total calories), low cholesterol (no more than 200 mg daily) diet Persons with Diabetes BP should be measured at each regular visit BP measured seated after 5 min rest in office Patients with 130 or 80 mmhg should have BP confirmed on a separate day Preventing Cancer, Cardiovascular Disease, and Diabetes A Common Agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association. Circulation. 2004;109: American Diabetes Association. Diabetes Care. 2007;30:S4-41. Non-pharmacologic DASH diet Dietary Approaches to Stop Hypertension High in whole grains, fruits, vegetables, and low-fat dairy Low in saturated and trans fat, cholesterol Physical Activity Weight loss, if applicable Pharmacologic Drug therapy indicated if BP 140/ 90 mm Hg Combination therapy often necessary Treatment should include ACE or ARB Thiazide diuretic may be added to reach goals Monitor renal function and serum potassium The Dash Diet. American Diabetes Association. Diabetes Care. 2007;30:S4-41. The Dash Diet. American Diabetes Association. Diabetes Care. 2007;30:S4-41.

17 Microvascular Renal disease Autonomic neuropathy Eye disease (glaucoma, retinopathy with potential blindness) Macrovascular Cardiac disease Cerebrovascular disease Reduced survival and recovery rates from stroke Peripheral vascular disease American Diabetes Association. Diabetes Care. 2007;30:S % of coronary heart disease deaths in the US can be attributed to an inactive lifestyle* Consistent exercise can reduce CVD risk* Exercise, combined with healthy diet and weight loss, is proven to prevent/delay onset of type 2 diabetes * American Diabetes Association. Diabetes Care. 2007;30:S4-41. Diabetes Prevention Program Diabetes Care 25: , Guidelines Fit into daily routine Aim for at least 150 minutes/week of moderate aerobic exercise Start slowly and gradually build intensity Wear a pedometer (10,000 steps) Encourage patients to take stairs, park further away or walk to another bus stop, etc. American Diabetes Association. Diabetes Care. 2007;30:S4-41.

18 Benefits of Exercise Increased insulin sensitivity Improved lipid levels Lower blood pressure Weight control Improved blood glucose control Reduced risk of CVD Prevent/delay onset of type 2 diabetes American Diabetes Association. Diabetes Care. 2007;30:S4-41.

19 Hazards Ratio (95% CI) Never Smoked 1 Ex-Smoker 1.08 ( ) Current Smoker 1.58 ( ) Set a Plan Offer counseling and referrals Offer medication assistance Offer combined pharmacologic and behavioral intervention Online guide to quitting: SmokeFree.gov R C Turner, H Millns, H A W Neil, I M Stratton, S E Manley, D R Matthews, and R R Holman. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS: 23) BMJ. 1998;316: American Diabetes Association. Diabetes Care. 2004;27:S27:S74-S75. OK, We ve Heard This Before Are there any studies that show that this really works? Diabetes Prevention Program (DPP) The DPP was a major clinical trial to determine whether diet and exercise or the oral diabetes drug metformin could prevent or delay the onset of type 2 diabetes. DPP Research Group. N Engl J Med 2002, Vol.346, No. 6.

20 DPP Participants Adults at high risk for type 2 diabetes Presence of IGT Mean age 51 years Mean body mass index (BMI) 34 68% women 45% minority groups African Americans Hispanics/Latinos American Indians Asian Americans and Pacific Islanders DPP Research Group. N Engl J Med 2002, Vol.346, No. 6. DPP Methods Lifestyle intervention 5% to 7% weight reduction Healthy low-calorie, low-fat diet 30 minutes of physical activity, 5 days a week Metformin Oral diabetes drug Placebo DPP Research Group. N Engl J Med 2002, Vol.346, No. 6. DPP Methods DPP Curriculum: Diet Exercise Behavior change modification Taught one-on-one by case managers DPP Research Group. N Engl J Med 2002, Vol.346, No. 6.

21 Diabetes Prevention Program Outcomes Study (DPPOS) Follow-up study to the DPP Assess the long-term effects of the DPP interventions on the development of type 2 diabetes and its complications Diabetes Prevention Program Outcomes Study (DPPOS) After 10 years follow up, lifestyle intervention: reduced the rate of developing type 2 diabetes by 34% reduced the rate of developing type 2 diabetes by 49% in those age 60 and older delayed type 2 diabetes by about 4 years reduced cardiovascular risk factors Reduced A1C and FPG DPP Research Group. The Lancet 2009: Vol.374, No Diabetes Prevention Program Outcomes Study (DPPOS) At 10 years follow up, metformin reduced the rate of developing diabetes by 18% compared with placebo. delayed diabetes by 2 years compared with placebo. reduced A1C and fasting glucose compared with placebo. DPP Research Group. The Lancet 2009: Vol.374, No Diabetes Prevention Program Outcomes Study (DPPOS) More results 8% of participants with pre-diabetes had diabetic eye disease (retinopathy) 12.6% of participants with type 2 diabetes who developed diabetes during the DPP had diabetic eye disease These findings suggest that patients with pre-diabetes or newly diagnosed type 2 diabetes should be screened for retinopathy. DPP Research Group. Diabetic Medicine 2007; 24 (2);

22 Patients with Events (%) Patients with Events (%) HR for CVD Effect of Regression from Prediabetes to Normal Glucose Diabetes risk during the DPPOS was 56% lower for participants who had returned to normal glucose regulation versus those who had persistent prediabetes. Reversion to normal glucose regulation, even if transient, is associated with a significantly reduced risk of future diabetes. L Perrault et al, The Lancet, Published online June 9, 2012, DOI: /S (12)60525-X Primary Outcome Years of Follow-Up ACCORD Results: Primary Outcome and All-Cause Mortality Results: Primary Outcome and All-Cause Mortality HR 0.90 ( ) p=0.16 Standard therapy: 2.29%/yr Intensive therapy: 2.11%/yr All-Cause Mortality Years of Follow-Up HR 1.22 ( ) p=0.04 Intensive therapy: 1.41% Standard therapy: 1.14% Standard The ACCORD Trial seemed to suggest that Intensive Glucose Regulation INCREASED All-Cause Mortality Intensive The ACCORD Study Group. N Engl J Med 2008;358(24): VADT: CV Outcomes by Glycemic Control Results: Relationship of DM Duration and HR for CVD Events Intensive Therapy (p<0.0001) DM Duration (years) Duckworth W. ADA Scientific Sessions, Symposia. June 8, 2008.

23 Age 47 Race/ethnicity African American Gender Male Family history HTN and diabetes Overweight/obesity BMI = 29 Abnormal lipid metab TC = 210 Hypertension BP = 146/86 Smoking 1 pack per day Physical Inactivity Sedentary Unhealthy diet Fast food diet Identify at-risk patients by evaluating a spectrum of predisposing risk factors The existence of any one risk factor is an alert to evaluate patient for others Integrate evidence-based risk management strategies to target modifiable risk factors Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2005;28 (9) Conclusions Prediabetes is incredibly common, and very costly. Most people with prediabetes are not aware that they have it. Their doctors may not be aware, either. If no steps are made to stop the process, most people with prediabetes will progress to diabetes within ten years. Conclusions (cont) Prediabetes is not only a risk for diabetes, it is a risk for heart disease. Waiting until a person develops diabetes to intervene may be too late! Some people with prediabetes already have microvascular complications (retinopathy, neuropathy, nephropathy) Prediabetes has a long prodrome, leaving people time to prevent progression.

24 Conclusions (cont) Weight loss is important to prevent progression, but exercise is probably the key. Aim for 30 minutes per day (150 minutes per week). Thank you! Questions? 95