Diagnosis and Management of Prediabetes in the Continuum of Hyperglycemia — When Do the Risks of Diabetes Begin? A Consensus Statement From the American College of Endocrinology and the American Association of Clinical Endocrinologists)

Alan J. Garber, MD, PhD, FACE; Yehuda Handelsman, MD, FACP, FACE; Daniel Einhorn, MD, FACP, FACE; Donald A. Bergman, MD, FACE; Zachary T. Bloomgarden, MD, FACE; Vivian Fonseca, MD, FACE; W. Timothy Garvey, MD; James R. Gavin III, MD, PhD; George Grunberger, MD, FACP, FACE; Edward S. Horton, MD, FACE; Paul S. Jellinger, MD, MACE; Kenneth L. Jones, MD; Harold Lebovitz, MD, FACE; Philip Levy, MD, MACE; Darren K. McGuire, MD, MHSc, FACC; Etie S. Moghissi, MD, FACP, FACE; Richard W. Nesto, MD, FACC, FAHA

Disclosures

Endocr Pract. 2008;14(7):933-946. 

In This Article

Introduction

A worldwide pandemic of obesity and diabetes is well advanced. In the United States alone, diabetes now affects an estimated 24.1 million people, an increase of more than 3 million in approximately 2 years. Twenty-five percent of persons with diabetes in the United States do not know they have diabetes. Another 57 million people in the United States have prediabetes,[1] defined as people with impaired fasting glucose (IFG) or impaired glucose tolerance (IGT), some of whom in fact already have the characteristic microvascular changes resulting from diabetes itself.[2,3] Worldwide, the number of people with prediabetes is estimated to be 314 million and is projected to be 418 million in 2025.[4] As the prevalence of and progression to diabetes continue to increase, diabetes-related morbidity and mortality have emerged as major public health care issues. Diabetes is expensive—the associated yearly cost of diabetes in the United States is $174 billion. Direct costs related to diabetes, diabetes complications, and general medical care are $116 billion, and indirect costs are $58 billion from illness, disability, and premature mortality.[5]

Prediabetes raises short-term absolute risk of type 2 diabetes by 3-to 10-fold, with some populations exhibiting greater risk than others.[6,7] People with diabetes are vulnerable to multiple and complex medical complications. These complications involve both cardiovascular disease (CVD) (heart disease, stroke, and peripheral vascular disease) and microvascular disease (ie, retinopathy, neuropathy, and microalbuminuria). Most patients with diabetes die of CVD.[8]

Epidemiologic evidence suggests that the complications of diabetes begin early in the progression from normal glucose tolerance to frank diabetes. Early identification and treatment of persons with prediabetes have the potential to reduce or delay the progression to diabetes[9,10,11,12,13] and related CVD[14,15] and microvascular disease.[16]

Despite the clear origins of diabetes-related complications early in the prediabetic state, few recommendations have been made for the diagnosis and management of patients with prediabetes. No medications are approved by the US Food and Drug Administration for addressing either IFG or IGT. Most insurance companies deny payment for lifestyle treatment to prevent diabetes. There are differences in opinion among health care professionals regarding the therapeutic approach to treating people with prediabetes. Many of these people already have diabetes related complications, yet there are no defined goals and targets of treatment in prediabetes for the many risk factors, which include glucose levels, weight, blood pressure, and lipid levels.

It is clear that the risks and adverse consequences of high blood glucose occur at much lower glucose levels than those at which we currently define as diabetes. Acknowledging these many challenges, there are major questions that health care professionals must address such as: "When do the risks of diabetes begin?"; "What can we do to prevent diabetes?"; "What strategies are necessary to reduce the vascular complications related to diabetes?"; and "How does society pay for the preventive costs of diabetes in the large number of patients at risk?"

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