​Kembara Xtra - Medicine - Glucose Intolerance

​Kembara Xtra - Medicine - Glucose Intolerance 
A stage in between diabetes and a normal glucose metabolism is glucose intolerance. It happens as a result of a progressive drop in -cell activity.

● Prediabetes is characterized by impaired glucose tolerance (IGT) and/or impaired fasting glucose (IFG) in a person. - IFG range: 100–125 mg/dL
- Two hours after ingesting a 75 g oral glucose load, IGT ranges from 140 to 199 mg/dL. - 5.7–6.4% Hemoglobin A1c (HbA1c)


Epidemiology 
One in three American people under the age of 20 is thought to have prediabetes as of 2010.

According to the National Diabetes Statistics Report, 88 million people in the United States aged 18 or older are estimated to have prediabetes as of 2020. Only 11% of those who have the condition are aware of it. Prediabetes affects 34.5% of adults over the age of 18 and 51% of adults under the age of 65 in the country.


Incidence

According to a systematic review, those with a HbA1c of 5.5–6.0% and those with a HbA1c of 6.0–6.5% have a cumulative incidence of diabetes of 9–25% and 25–50%, respectively, over the course of five years.

 Hispanics, non-Hispanic blacks, and American Indians/Alaska Natives have the highest incidence rates.
Prevalence
In the United States, the prevalence of prediabetes was 34.5% in those over 20 and 51% in those over 65 as of 2020. The ADA estimates that 84.1 million Americans over the age of 18 had prediabetes in 2015. 2010 saw an 8% global prevalence.

Pathophysiology and Etiology 

On the backdrop of insulin resistance, there is a progressive reduction of insulin secretion. Genetics
Studies on family, twin, immunologic, and HLA illness correlation have proven that there is genetic heterogeneity.
It has been demonstrated that variations in 11 genes are strongly related to the emergence of type 2 diabetes and IFG in the future. Impairment of -cell function has been linked to variants in 8 of these genes.


Risk factors include having a body mass index (BMI) over 25, being overweight, having a history of gestational diabetes, living a sedentary lifestyle, and taking medications.

Prevention: A reduction in excess body fat offers the greatest risk reduction. Lifestyle adjustment includes weight loss and improved physical exercise.

Considerations During Pregnancy Risk factor analysis is used to guide diabetes screening during pregnancy: Women with GDM should be evaluated for diabetes six to twelve weeks after delivery with a 75-g OGTT, and thereafter every one to three years using any technique. - High risk: first prenatal visit - Average risk: 24 to 28 weeks' gestation.

Obesity (including visceral and abdominal obesity), dyslipidemia with elevated triglycerides (TG), PCOS, GDM, and congenital illnesses like Down, Turner, Klinefelter, and Wolfram syndromes are all associated conditions.

Diagnosis 
whom to check

 History of GDM History of cardiovascular disease Ethnic group at increased risk (non-Hispanic black, Native American, Hispanics, Asian American, and Pacific Islander) PCOS Conditions associated with insulin resistance such as severe obesity or acanthosis nigricans BMI 25 or 23 for Asian Americans Age 45 years First-degree relative with diabetes High TG >250 mg/dL 

Symptoms not clearly defined, polyuria, polydipsia, weight loss, blurred eyesight, and polyphagia in the history

Clinical Exam, Comprehensive Physical Examination, and BMI Calculation

Type A insulin resistance, Leprechanism, Rabson-Mendenhall syndrome, Lipoatrophic diabetes, Pancreatitis, Cushing syndrome, Glucagonoma, Pheochromocytoma, Hyperthyroidism, Somatostatinoma, Aldosteronoma, and Drug-Induced Hyperglycemia are all possible differential diagnoses. - High-dose thiazide diuretics
Atypical antipsychotics, blockers, corticosteroids, especially inhaled corticosteroids, thyroid hormone, pentamidine, protease inhibitors, thyroid hormone, and selective serotonin reuptake inhibitors

Laboratory Results 
Initial examinations (lab, imaging)
Fasting blood sugar, a 2-hour OGTT, or HbA1c are all acceptable measurements.

Repeat screening with normal results every three years, or earlier depending on risk status.


Tests in the Future & Special Considerations
Microalbumin-to-creatinine ratio, thyroid-stimulating hormone with free T4, fasting lipid profile, creatinine and GFR, urine analysis, thyroid-stimulating hormone with free T4, and periodic monitoring of vitamin B12 levels for patients on long-term metformin therapy, particularly those with anemia or peripheral neuropathy.

Management 

The Mediterranean diet and diets high in fiber-rich foods like vegetables, fruits, whole grains, seeds, and nuts as well as white meat sources are protective against type 2 diabetes. Therapeutic lifestyle modifications to include physical activity focused on weight loss and medical nutrition therapy (preferably via a registered dietitian) are also recommended.

Consider referring prediabetic patients to a rigorous diet and exercise program adhering to the Diabetes Prevention Program's principles in order to lose 7% of their body weight. They should also up their moderate-intensity exercise (such as brisk walking) to at least 150 minutes per week.

Both resistance training and endurance training lower the chance of developing diabetes.
Diabetes preventive programs are affordable and frequently funded by third-party payers. Every 30 minutes, break up extended sitting with brief periods of physical exercise. 

Diabetes self-management education and support systems are ideal places for persons with prediabetes to obtain instruction and assistance to develop and maintain behaviors that can prevent or postpone the onset of diabetes. Screen and treat modifiable risk factors for cardiovascular disease. 

Internet-based social networks, distance learning, DVD-based content, and mobile applications are examples of technology-assisted tools that can be helpful in modifying one's lifestyle to successfully prevent diabetes.

Medication 
Think about using metformin to prevent type 2 diabetes, especially if you have a BMI > 35, are under 60 years old, or are a woman with a history of GDM or rising HbA1c despite lifestyle changes (6)[C].
Initial Line
Metformin (preferred medication): 500 mg BID or 500 mg XR at first. According to observational data, it may need dose changes but can be used safely down to GFR of 30 to 45.


Next Line
Acarbose: GI upset is common; dosage is typically started at 50 mg PO once day and increased to 100 mg PO TID.
Agonists of GLP-1 GLP-1 agonists have demonstrated a number of benefits in recent clinical studies in mostly obese patients, including weight loss, improved B-cell activity, and a return to a normal glycemic state. The incidence of prediabetes overall decreased by 84-96%. However, as of 2020, the FDA has not approved any GLP-1 inhibitors for prediabetes.

Referral: Exercise physiologist, certified dietitian upon diagnosis of diabetes, lifestyle coach, and obesity specialist

Additional Therapies Alternative/Botanical Therapy: There is some evidence that fenugreek, bitter melon, and cinnamon can lower hyperglycemia and enhance insulin sensitivity, despite studies lacking large sample sizes and perfect design.


Patient Follow-Up Monitoring
HbA1c, 2-hour OGTT, or fasting glucose testing should be used at least once a year to check for the onset of diabetes.
BP should be checked on a regular basis.
Annual testing for lipid abnormalities and microalbuminuria (to identify and alter treatment for developing diabetic nephropathy)

Diet

The benefits of the Mediterranean diet have been established. One small cohort research found that adding roughly 10 g of extra virgin olive oil to meals reduced DPP4 activity and increased insulin and GLP-1, which decreased postprandial hyperglycemia. A considerable decline in TG and apolipoprotein B-48 was also seen.
Limit foods with high glycemic indexes and those that include sugar. Consume a diet rich in fiber, vegetables, nuts, seeds, and whole grains. 
Studies have demonstrated that intermittent fasting is beneficial for reducing postprandial hyperglycemia and enhancing fasting glucose.


Prognosis People with IFG and/or IGT are at a significant risk of developing diabetes in the future.
Type 2 diabetes, heart disease, and stroke risk are all increased by prediabetes.

 Lifestyle intervention reduced 3-year diabetes incidence by 58% compared to 31% with metformin. 20–70% of people with prediabetes who do not lose weight, improve their food choices, and/or participate in moderate physical activity would develop to type 2 diabetes within 3–6 years.

Complications include: Stroke: 2 to 4 times increased risk Ketoacidosis Sexual dysfunction Gastroparesis Nephropathy and possibility for renal failure Gastroparesis
Retinopathy, which increases the risk of visual loss, as well as peripheral and autonomic neuropathy