Understanding Pre-diabetes and insulin resistance

What is pre-diabetes?

Pre-diabetes is defined as the higher blood glucose levels than normal range but not high enough to be diagnosed as diabetes. That is why it is also called as the Borderline diabetes. 

It occurs in those people who already have some insulin resistance or whose pancreatic beta cells do not produce enough insulin to keep blood glucose in the normal range. 

It does not show any clear symptoms for years, so there is a high chance that it often goes undetected until serious health problems shows up. 

Want to know about PCOS? Check out this article. A comprehensive guide- PCOS and Dietary Habits

What is the prevalence of prediabetes?

In the United States, it is estimated that 84 million adults in the USA have prediabetes in 2015 and that’s about 1 out of 3 adults. 

According to a study published in the Indian Journal of Medical Research in 2018, the estimated prevalence of prediabetes in India is 14%. And this data only includes just those people who have been tested. (Source-How should one tackle prediabetes in India?)

According to a survey by National Health of India and National Center of Biotechnology Information, 70.5% of pre-diabetes cases were found in 25–44 age.

While 40% and 51.4% of diabetes cases were found in 25–44 and 45–60 aged individuals, respectively. Pre-diabetes is more prevalent in middle age (25–44 age group) and diabetes in 45–60 age group.

The prevalence of prediabetes is growing worldwide, and authorities have estimated that more than 470 million people will have prediabetes by 2030 (Sethuram K et al.).

What are the stages of diabetes?

Figure: Stages of diabetes

Stage 1: Insulin resistance

Insulin is a hormone which is produced by the beta-pancreatic cells that helps glucose to enter in your muscle, fat, and liver, and use it for energy. 

The insulin resistance occurs when cells in your muscles, fat, and liver do not respond well to insulin.  And because of that, blood glucose cannot be used for energy. In turn, your pancreatic cells make more insulin to help glucose enter your cells. 

If your body becomes insulin resistant, this is what happens:

• Rise in blood glucose (blood sugar) after you eat.
• Then beta-pancreatic cells produces insulin, but it does not enter the cells and the glucose isn’t introduced to the cells efficiently.
• Now, glucose stays in your blood because your cells aren’t burning the glucose for energy.
• Over time, continuous high blood sugar levels damage your cells. It may lead to nerve damage, blood vessel and organ damage, cardiovascular disease and more.

Figure: Insulin Resistance cycle

(Image source: Insulin Resistance: Causes, Symptoms, Prevention – This silent condition increases your risk of diabetes, heart attacks, and more)

If this insulin resistance occurs for a long time, it may develop into prediabetes. 

Stage 2: Pre-diabetes

Pre-diabetes is also called borderline diabetes. Because it is at the verge of becoming diabetes mellitus but can be reversed if right measures are taken beforehand.

The most important thing about prediabetes is that it is reversible. You can prevent or delay prediabetes from developing into diabetes with a change in your lifestyle.

It is a serious condition and if not treated, then it can develop into diabetes.

Figure: Pre-diabetes cycle

(Image Source- The Stages of Diabetes: A Guide)

Stage 3: Diabetes

Diabetes is a group of disorders, characterized by high blood glucose concentrations resulting in insulin secretion, insulin action or both. In other words, hyperglycemia develops gradually due to a progressive loss of beta-cell insulin secretion with insulin resistance. 

Stage 4: Post diabetes:

If your blood sugar levels are too high for a long time, then it can lead to serious health problems including heart, nerve, kidney, eye damage and more.

It affects the microvascular and macrovascular of your bodies.

Microvascular diseases due to diabetes:

Diabetes is an important risk factor for Microvascular diseases affecting small blood vessels: retinopathy, nephropathy and neuropathy.

Diabetic retinopathy:

Diabetic retinopathy is the diabetic eye disease which includes all disorders of the retina caused by diabetes. It is the leading cause of blindness in people with diabetes and silent complication with no initial symptoms.

But when symptoms occur, treatment is more complicated and often impossible.

Diabetic nephropathy/Diabetic kidney disease:

Diabetic nephropathy is a condition caused by damage to the filtering system of the kidneys.

In severe cases, it can lead to kidney failure. The long standing diabetic nephropathy can lead to Chronic kidney disease (CKD).

Figure: This cycle shows how Chronic Renal Failure occurs due to diabetes.

(Source: http://www.idf.org/diabetes-education-modules)

Diabetic neuropathy:

Diabetic neuropathy is a group of nerve disorders caused by diabetes. It causes numbness and sometimes pain and weakness in the hands, arms, feet and legs. Longer the duration of diabetes, the greater the risk.

American Dietetic Association recommendations for screening of diabetic neuropathy:

1. All patients should be assess for diabetic peripheral neuropathy starting at diagnosis of diabetes at least annually thereafter.
2. Assessment for distal symmetric polyneuropathy should include a careful history and assessment of either temperature or pinprick sensation (small fiber function) and vibration sensation using a 128-Hz tuning fork (for large-fiber function)
3. All patients should have annual 10-g monofilament testing to identify feet at risk for ulceration and amputation
4. Symptoms and signs of autonomic neuropathy should be assess in patients with microvascular complications.

Macrovascular diseases due to diabetes:

Diabetes is an important risk factor for Macrovascular diseases affecting large blood vessels: Cardiovascular disease (CVD), Cerebrovascular disease, Peripheral vascular disease (PVD).

Cardiovascular diseases (CVD):

CVD complications are one of the most common causes of morbidity and mortality in people with diabetes.

Coronary Artery Disease, stroke and Peripheral Vascular Disease are increased by 2 to 4-fold in people with diabetes.

Symptoms include chest pain, chest tightness, chest pressure and chest discomfort (angina), shortness of breath. It also include pain, numbness, weakness or coldness in your legs or arms if the narrow blood vessels are present.

Cerebrovascular diseases:

Cerebrovascular diseases can occur due to sudden narrowing or occlusion of brain blood vessels.

Symptoms include sudden weakness or numbness of face, arm, leg on one side of the body, sudden confusion, sudden dizziness, loss of balance, visual impairment and sudden severe headache.

Peripheral vascular disease (PVD):

PVD is defined as the reduced blood supply due to occlusion/narrowing of peripheral blood vessels. It is a risk factor for diabetic foot amputations. 

Symptoms include pain on doing any activity, calf pain, numbness in hands and feet.

Other complications due to diabetes:

Liver diseases/liver failure:

Liver is a multi-functional organ. One of the liver’s many jobs is regulating blood sugar, but fat in the liver makes that organ less responsive to insulin. In turn, leaves too much glucose in the blood, which can lead to type diabetes.

Diabetes raises your odds of having a more severe form of Non-Alcoholic Fatty Liver Disease, also known as nonalcoholic steatohepatitis (NASH). Fatty liver disease itself usually causes no symptoms. But it raises the risk of developing liver inflammation or scarring (cirrhosis).

It’s also linked to an high risk of liver cancer, heart disease and kidney disease.

Last stage: Death due to diabetes

In 2014, 8.5% of adults aged 18 years and older had diabetes. In 2019, diabetes was the direct cause of 1.5 million deaths and 48% of all deaths due to diabetes occurred before the age of 70 years. Both types of diabetes can also lead to other long-term complications, like kidney disease, that may result in premature death. Problems like vision loss, nerve damage and infections that may lead to amputations can increase the likelihood of injuries and accidents.

Between 2000 and 2016, there was a 5% increase in premature mortality rates (i.e. before the age of 70) from diabetes.

(Source-https://www.who.int/news-room/fact-sheets/detail/diabetes ).

Who is more likely to develop insulin resistance or prediabetes?

People who have genetic or lifestyle risk factors are more likely to develop insulin resistance or prediabetes. These risk factors include

• overweight or obesity
• Old age-usually 45 years or older
• Genetic factor- a parent, brother, or sister with diabetes
• physical inactivity/sedentary lifestyle
• health conditions such as hypertension and abnormal cholesterol levels, heart disease or stroke
• a history of gestational diabetes
• a history of heart disease or stroke
• polycystic ovary syndrome, also called PCOS

People who have metabolic syndrome—a combination of high blood pressure, abnormal cholesterol levels, and large waist size—are more likely to have prediabetes.

How can you diagnose pre-diabetes?

To test for prediabetes, these 2 tests are the most important:

• Fasting plasma glucose test, which tests your blood after you have fasted for eight hours.
• HbA1C or glycated hemoglobin test, which provides your average blood glucose level over the past two to three months.

You would be diagnosed with prediabetes if:

• Your fasting plasma glucose test is 100 to 125 mg/dL (normal is <100; diabetes is 126 or higher).
• Your HbA1c test is 5.7% to 6.4% mg/dL (normal is < 5.7%); diabetes is 6.5% higher.

Figure: Pre-diabetes diagnostic test and criteria

(Image source: Recommended Tests for Identifying Prediabetes | NIDDK)

Is there a test for insulin resistance/Pre-diabetes?

There is a HOMA-IR test that determines if there is insulin resistance or not.

HOMA-IR stands for Homeostatic Model Assessment of Insulin Resistance or Pre-diabetes. It is an index which determines if a patient has insulin resistance. The blood tests like HbA1C or fasting sugar (glucose) levels may be normal, but if the insulin levels are high, this means that your body may be struggling to maintain normal blood sugar levels. This may be the precursor to diabetes. 

Your results from the HOMA-IR test are displayed against a reference scale or range that determines the level of your insulin resistance. 

Low HOMA-IR implies that you are sensitive to insulin. On the other hand, higher levels indicate insulin resistance and higher chances of you developing diabetes.

Interpretations of HOMA-IR lab test:

• Optimal insulin-sensitivity- less than 1.0
• Early insulin resistance- above 1.9
• Significant insulin resistance- above 2.9

Labs from where you can get your HOMA-IR test done:

TATA 1 mg: HOMA IR C – PEPTIDE MODEL : Purpose & Normal Range of Results | 1mg 

Apollo 24×7: Homa IR Test – Price, Procedure, Preparation, Range – Apollo 24|7

Lal path lab: homa-ir ; insulin resistance index 

How can you treat or reverse insulin resistance and prediabetes?

It is possible to reverse the insulin resistance or prediabetes if diagnosed early. You can achieve it through lifestyle changes such as diet and exercise.

In other words, taking small steps, such as eating healthier foods and moving more to lose weight, can help reverse insulin resistance. Also, prevent or delay type 2 diabetes in people with prediabetes.

Don’t rely on dieting or exercise alone: In one University of New Mexico School of Medicine study, published in the International Journal of Obesity, overweight people who lost 10% of their weight through diet plus exercise saw insulin sensitivity improve by an impressive 80%. Those who lost the same amount of weight through diet alone got a 38% increase. 

Dietary guidelines to improve glycemic control:

• Firstly, a moderate calorie restriction of about 500-750 calories from usual daily intake and an increase in physical activity by 30 minutes/day may lead to improved insulin sensitivity.
• Avoid whole milk and prefer skimmed milk for tea, coffee, curd, paneer, etc.
• Choose lean sources of protein such as fish, skinless chicken, low-fat cottage cheese, turkey or ground turkey breast, etc. Protein helps to stabilize blood sugar.
• Prefer whole grain cereals like millets, oats, quinoa, barley, long grain basmati rice and whole pulses.
• Avoid refined carbohydrates like sugar, juices, jams, jellies, candies, honey, jaggery and chocolates.
• Also, increase your fiber Intake. Fruits and vegetables are a good source of fibre such as pears, apples, dried figs, berries, green leafy and seasonal vegetables.
• Limit roots and tubers like potato, arbi, sweet potato, and beetroot.
• Sago, arrowroot and refined flour preparations like white bread, biscuits, sago poha, noodles and pasta should be avoided.
• Also, reduce the intake or eliminate fried and creamed foods.
• Emphasize on eating healthy and omega-3 rich sources such as fish, nuts and oilseeds.
• Read the nutrition label carefully. Products that are “sugar-free”, “fat-free” or high fibre do not necessarily have a reduced number of calories or carbohydrates also.
• Drink plenty of water as it may help in controlling blood glucose levels, and it’s also a healthy substitute for sodas and fruit juices.
• Portion control can keep with your carbohydrate control. Practice mindful eating for your portion control.

The most important thing to consider when choosing foods to incorporate into diet is to aim for balance, variety, and moderation. Your goal should be to adopt an eating pattern that is sustainable and that you can stick with long-term, while still incorporating foods you enjoy.

Physical activity and exercise:

Clinical guidelines from the American Diabetes Association suggest exercising for at least 30 minutes a day, five days a week. If you have a strong family history of type 2 diabetes, it might be best to take it up a notch to 45 to 60 minutes a day.

Furthermore, losing as little as 5 to 10 percent of body fat can improve your blood sugar level and help reverse prediabetes.

Stop smoking:

Everyone knows that smoking increases the risk for heart disease and lung cancer. But smoking is also a risk factor for insulin resistance, prediabetes, and type 2 diabetes. So, quitting smoking is the best idea to reverse insulin resistance and prediabetes.

Get proper sleep everyday:

In a study presented at the 2015 meeting of the Obesity Society, researchers found that just one night of sleep deprivation boosted insulin resistance as much as eating high-fat foods for six months. So, get at least 8 hours of sleep for a better insulin production and usage by your cells.

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