Erik Russell, M.D.

Pre-Diabetes is a relatively new term for a condition of abnormal glucose metabolism wherein the patient has periods of both hyper and hypo glycemia, but without meeting the formal definition of type 2 diabetes mellitus. An individual may show evidence of being pre-diabetic for many years before actually transforming into a full type 2 diabetic. In some instances, a person may be pre-diabetic for much of his or her adult life without ever making that transformation.

In addition to putting a patient at risk of developing full type 2 diabetes at some point in the future, pre-diabetes may also lead to many or all of the same complications known to afflict the diabetic patient. These complications include: obesity, hypertension, dyslipidemia (disorders of cholesterol and triglycerides), atherosclerosis, heart attack, stroke, peripheral arterial disease (poor circulation in the lower extremities), blindness due to retinopathy, kidney failure due to nephropathy, damage to nerves of the feet and hands called peripheral neuropathy, and many others.

Not many years ago, pre-diabetes was thought to be treatable only by diet, exercise, and (where necessary) weight loss. Now many other approaches for treatment are being employed, including lower doses of many of the same medications used for full diabetes itself. Therefore, early detection of and intervention for pre-diabetes is now deemed essential by most medical authorities.

Symptoms
Many people with pre-diabetes suffer no identifiable symptoms of which they are aware. However, some do have episodes of hypoglycemia, which can cause periods of lightheadedness or dizziness, hot flashes or chills, tremors in the hands, anxiety or nervousness, headaches, sweats, palpitations (sensation of a rapid or irregular heart beat), and fatigue or exhaustion. Body aches may also occur, as do occasional painful muscle spasms (such as "charlie horses"), abdominal cramps, urgency to urinate or defecate, nausea, and sometimes other gastrointestinal symptoms. Mood swings are also frequent with rapid variations in blood sugar, and patients may experience emotional highs and lows all occurring within a 30 to 120 minute period. These symptoms often resolve within 5 to 15 mintutes after consumption of food or drink containing sugar or starch; i.e., carbohydrate.

So-called medical "signs" of pre-diabetes, which are the observable features of a condition that physicians are trained to note in a patient, would include the mild hyperglycemia and hypoglycemia often seen during an office visit, weight gain and associated difficulty losing it, and the tendency to develop hypertension and lipid abnormalities. The latter has become a hallmark of the syndrome when the classic pattern of elevated triglycerides along with low HDL is seen. However, other lipid abnormalities may be witnessed as a part of pre-diabetes, and in the earlier phases of the syndrome no cholesterol or triglyceride problems may be detectable at all.

Diagnosis
Unlike the formal diagnosis of type 2 diabetes, there is unfortunately no current standard used for the diagnosis of pre-diabetes. A variety of different criteria are used, mostly informally, by different authorities. However, all sources agree that if three or four of the associated conditions (impaired glucose tolerance, obesity, dyslipidemia, and/or hypertension) are present, the patient most likely suffers from pre-diabetes. Therefore, this condition is a pattern-recognition illness whose presence physicians infer once the constituent members of the tetrad are noted.

Treatment
As with the diagnosis, treatment approaches for pre-diabetes vary according to the individual providing the medical care. Nearly all medical professionals today agree that pre-diabetes is a significant and potentially dangerous condition requiring early detection and some form of treatment. There is also consensus that the first step in that treatment should be a proper diet (high fiber, high lean protein, low fat, and low carbohydrate), regular exercise, and if the patient is overweight -- as determined by BMI -- weight loss should be included as well. However, if these measures fail to bring the various features of pre-diabetes under control, some physicians will advocate the use of lower doses of certain diabetic medication, and other doctors will advise no further intervention unless the patient progresses to full type 2 diabetes.

It should also be recognized that the concept of the aggressive treatment of pre-diabetes (i.e., with prescription medication) is so new that no medications have been approved by the FDA for that purpose. Although this fact does not prohibit physicians from prescribing pharmaceuticals for the treatment of pre-diabetes, some doctors strictly follow FDA guidelines as a means of providing the generally accepted "standard of care".

Purpose and Outcome of Treatment
The purpose of aggressively treating pre-diabetes is two-fold: delay or prevent the progression of the disease to full type 2 diabetes; prevent the development of or reduce the number and/or severity of diabetic complications. Early research has shown that treatment of pre-diabetes with prescription medication has delayed or prevented the onset of type 2 diabetes in some cases, for short periods of up to a few years. Since this branch of medicine is still quite young, much more study must occur to confirm these results and extend their findings. Current studies are ongoing to show that preventing or reducing the complications of diabetes by the use of medications will occur.

An emerging third purpose of treating pre-diabetes with prescription medication is to reduce or eliminate the symptoms -- mostly those of the hypoglycemia component. In addition to the many possible symptoms listed above, a fair proportion of individuals suffering from pre-diabetes also have discomfort associated with early peripheral neuropathy. This is often experienced as a burning, numbness, pins-and-needles sensation, pain, heat, or cold sensation in the feet mostly, and occasionally in the hands as well. While consuming food or drink containing carbohydrate at the time of an acute episode of hypoglycemia often brings temporary relief, it is not a good long-term strategy in the treatment of this syndrome, and does nothing at all for the discomfort of peripheral neuropathy. Individuals with pre-diabetes who have experienced successful treatment of the syndrome with diet, exercise, and weight loss often report reduction or elimination of the symptoms of hypoglycemia and peripheral neuropathy. In others where this approach has not been effective, symptom reduction or elimination has often been achieved through the use of certain diabetic prescription medication.

Though much medical research is ongoing concerning the use of medication to treat pre-diabetes for the purpose of delaying onset of full type 2 diabetes and diabetic complications, more studies are necessary showing that medication is effective and appropriate for symptom reduction or elimination. Only when the medical literature has abundant citations in this regard will aggressive treatment of pre-diabetes by health care providers become main stream, and the "standard of care".

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