Melanie Cole (host):

Welcome to Bryan Health Podcast. I'm Melanie Cole. And today, we're going to learn about prediabetes and really what it means for you if you've been told that this is something that you have. Joining me is Gretchen Johnson. She's a registered dietician at the Bryan Diabetes Center. Gretchen, thank you so much for joining us today. So, as I said in my intro, we're going to learn about it. So, tell us what is prediabetes. How common is that?  

Gretchen Johnson:

So, prediabetes is when we see that our blood sugar levels are running higher than normal, but they're not at the range yet where we have real or diagnostic for diabetes. So, it might not be a lab that everyone's familiar with, but usually the one that we find with prediabetes that your doctor might check is your hemoglobin A1c. So, we see when that gets to a range of 5.7 or above, so between 5.7 to 6.4, that's in our range for prediabetes. And it's very common. So, according to the CDC, it's estimated around 115.2 million US adults have prediabetes. And older individuals over that age of 65 are usually the most affected, around 31.3 million or about 52%, so a lot of the US population.

When we think about kind of the cause or maybe what's going on in our body with prediabetes, it's often our body's not properly using glucose anymore. So when we eat, our body breaks that down into sugar that enters our bloodstream, and our body wants to use that sugar for energy. In prediabetes, what we see is that our cells are not as open to it. So, they need insulin to bring that sugar into our cells. And what we see with prediabetes is we're a little resistant to insulin. So, we need more than we used to. Usually, I try to think of, or when I talk with patients about prediabetes, insulin is that key that helps to open our cell. And insulin resistance, I almost think of our lock is rusty or the key doesn't quite fit. So, it's kind of that we're needing more insulin than we used to. So, that's kind of what's going on in our body. 

Host:

Yeah. Wow. And we're going to talk a little more about A1c in a minute. But as we think of the obesity epidemic that's going on in the country today, Gretchen, and how many people are getting full-blown diabetes, when you're told that your A1c is that high and that you are a prediabetic, does that mean that the person's automatically going to get diabetes if they don't do any sort of treatment or lifestyle behaviors, which we're going to talk about? 

Gretchen Johnson:

Yeah. So, it's definitely different for everybody. I think for some people it would potentially progress quicker than others. But no, it does not automatically mean. If we don't make any changes, it does mean, you know, maybe we are on that trajectory of our body's not doing the best job of managing our blood sugar levels anymore. So if we kind of keep our same habits and we don't make any changes, that is kind of, yes, we see that down the line, we will develop type 2 diabetes. 

Host:

It's so interesting what we're seeing happen. And just for the listeners so they know, we are talking type 2 diabetes, not type 1, which is, you know, a juvenile onset and something. We're not talking about that today. So, when we think of prediabetes risk factors, do we know what the actual cause do we know who's affected the most? Tell us a little bit about what you see in clinic every day about people coming in and the risk factors for this. 

Gretchen Johnson:

Yeah. So, I'll get back to the risk factors. When we think about kind of the cause or maybe what's going on in our body with prediabetes, it's often our body's not properly using glucose anymore. So when we eat, our body breaks that down into sugar that enters our bloodstream, and our body wants to use that sugar for energy. In prediabetes, what we see is that our cells are not as open to it. So, they need insulin to bring that sugar into our cells. And what we see with prediabetes is we're a little resistant to insulin. So, we need more than we used to. Usually, I try to think of, or when I talk with patients about prediabetes, insulin is that key that helps to open our cell. And insulin resistance, I almost think of our lock is rusty or the key doesn't quite fit. So, it's kind of that we're needing more insulin than we used to. So, that's kind of what's going on in our body. And we're not exactly sure what maybe causes someone to become prediabetic. There's a mix of, you know, family history, genetics and a lot of different lifestyle factors. So again, of course, that family history we see, being overweight, so kind of the more fatty tissue that we have the more resistant our cells are to insulin. Kind of related to that with waist circumference, when we see that our waist, you know, for men is over 40 inches, or for women larger than 35 inches, we have an increased risk of that insulin resistance. So a diet high in those sugar-sweetened beverages and kind of more highly processed meats and other highly processed foods.

And then, we also see inactivity. So in general, you know, not doing formal exercise, but then also just having a more sedentary lifestyle, having more of an office job where we're sitting all day, that can increase our risk. And then, some other ones: smoking can, having gestational diabetes, so that's diabetes during pregnancy, we see that as a risk factor for developing prediabetes, and then also high blood pressure and high levels of triglycerides. 

Host:

So, that's quite a list. And obviously, really the complications, the comorbid conditions that go along with those things. As you mentioned, blood pressure, which then increases our risk for heart disease and so does diabetes. So, all of these things. Now, Gretchen, at the very beginning, you mentioned A1c, hemoglobin A1c. This is our marker. And you mentioned the numbers 5.7, 6.4. I'd like you to speak a little bit about A1c. How do we test for it and why is it important to know this number? What does it even really mean? 

Gretchen Johnson:

So, hemoglobin A1c, it's a blood test, so when you go to your doctor, oftentimes, at like a yearly physical or wellness check, it'll be a part of those labs that your doctor is taking. Not every doctor, but most will. And it correlates to your blood sugar levels on average. So, what it's looking at is how much sugar is on your red blood cells. And our red blood cells live for about three months in our body. So, it kind of can give us a picture of the past three months, what have your blood sugar levels been running at. So then, from that we can see, okay, you know, if it is higher than we're expecting, that shows that, you know, in the past three months, our blood sugars are running higher than they're supposed to be, or higher than we're wanting them to be, if that makes sense. 

Host:

It does, and that's really important to know all of our numbers, to know what your blood pressure is, to know what your glucose and fasting glucose, what those things are, it's so important. So now, the big question, the million-dollar question. If someone is told that maybe they're at 5.7 or even a little higher, they're told that they have prediabetes, what is the first-line of defense? What are you doing for them at the Bryan Diabetes Center?  

Gretchen Johnson:

Our first thing that we want to do is we're trying to think of ways, okay, how can I increase my insulin sensitivity? And that's through kind of a bunch of different lifestyle changes. When we lose 5-7% of our body weight, so not a huge amount of body weight, that can help to increase our sensitivity. So most of the time, we're targeting a little bit of weight loss and then also increased activity. What's really cool about activity is we have this kind of broken process where we have a little bit more sugar in our blood than we want, and our insulin is maybe not doing as good of a job, you know, we're still resistant. When we use our muscles, that can use the sugar. So, we're kind of bypassing that process of not having enough insulin and that can help to bring our blood sugar levels down as well. So, those are kind of the first things that we want to look at, is how can we lose some weight, change our eating habits and increase our activity. 

Host:

So Gretchen, tell us a little bit about the Bryan Diabetes Prevention Program. Tell us about what it includes, some of the class details, and information for listeners, like does Medicare cover this? 

Gretchen Johnson:

Yeah, of course. So our diabetes prevention program, it runs for about a year and it's composed of 22 different sessions. So it starts out pretty intense where we're meeting every week for about eight weeks and then it tapers off, to that last six months of just once a month check-in mostly for accountability. Those main focuses that we're looking at is, 5 to 7% loss of body weight, so looking at some weight loss and then also, increasing exercise. So we go back and forth between me, a registered dietician, and then we have an exercise specialist as well. So we kind of hit all those different topics, what to eat, how to eat, when to exercise, what exercises are gonna be the best. And then we also kind of incorporate different things too about, how to get back on track or how to stay motivated, managing stress and other things as well. So we really try to cover kind of that whole picture. In terms of coverage, if you meet that eligibility of having that diagnosis of prediabetes and having a BMI of 25 or above, Medicare does cover the program, which is great and that's a big portion of our population that comes into our program is that Medicare, which is really fun. And then, some other insurances may cover it. It kind of just depends on the insurances, if you are eligible with that diagnosis of prediabetes. 

Host:

Well, thank you for that. So tell us about the results that people who take these classes see. What have you seen? 

Gretchen Johnson:

So I've seen a lot. Right now I have two classes that started in February, and I think at least half of them, if not more, have reached that 5% loss of body weight, which is super exciting to see. I've had a couple that have reached that 7% or even 9%. And then from a class that already finished, we've had a couple that have dropped from their A1C, you know, in that pre-diabetes range to within those normal limits, which is really exciting. I think we had one gal that went from, 6.4, so right on the edge of almost being diabetic to 5.4 in that normal range, which was really, really exciting to see. 

Host:

As lifestyle management remains basic to long-term diabetes and certainly prediabetes management, Gretchen, there's certainly no one-size-fits-all rules. So, speak a little bit about the latest recommendations for prediabetes if lifestyle management doesn't seem to move the needle. 

Gretchen Johnson:

That is kind of what we're going for lifestyle management. Some doctors will potentially do a metformin medication, which is also used in diabetes that can help to tell your liver to not give you as much of that extra sugar. So, sometimes people will start with that. Another thing that I've kind of been starting to do as well that I think can be really helpful for people to see is maybe trialing wearing a continuous glucose monitor, and just kind of being more aware of what they eat and how that's impacting their blood sugar levels. That can kind of give patients a really clear picture of, "Okay, I didn't realize that that's what this is doing to my blood sugar levels" and can kind of help them to make those practical changes. But right now, it really is lifestyle and in some cases it is some metformin or potentially, you know, if they have some other comorbidities, potentially like a GLP-1 or something like that as well. 

Host:

Can it be reversed? 

Gretchen Johnson:

Yes. So, there are definitely ways to bring our levels back down into that normal range sometimes. We don't always say reverse, just because, you know, if we stopped doing all of those lifestyle changes we made or if we lost weight, we changed our eating habits and then we went back to our old habits, it potentially would come back, if that makes sense. So, sometimes it's not necessarily that it's a hundred percent gone because we're doing all these great things to manage it. But yes, it can definitely be managed. We can lower our levels, and we can no longer be in that prediabetes range. 

Host:

See, that's what's so great to learn here today, Gretchen. And as a registered dietician, do you have some food advice? You really spoke about sweetened beverages and eliminating those. But people hear that word carbohydrate and right away they think, "Oh, I can't have any of those now that I'm prediabetic or have prediabetes." But not all carbohydrates are created equal, right? And, I mean, I even know people that were like, "Well, I can't I have lentils now." Because I'm like, "Yeah, you could have lentils because they're so good for you." Speak a little bit. When you work with your patients every single day, how do you help them with the diet portion with some foods that can actually help regulate those blood sugar levels and some foods that are really, really bad for it. 

Gretchen Johnson:

No, you're exactly right about that carbohydrate or that becomes a scary word. And it really is how we balance our meals, and also what carbohydrates we're choosing. So, yes, exactly like you said, I would love for people to have lentils every day as opposed to potato chips or something like that, even though those are both in that carbohydrate category. One of the main things that we work on is just how to balance our meals. So, we know that carbohydrates impact our blood sugar levels. But when they're paired with a source of protein and some fat and also some fiber, that helps to balance it, and then we're not going to see as high of a blood sugar spike. So, it's going to prevent our blood sugar levels from going high. So usually, a lot of problem solving or thinking of ways of how can I build a really balanced meal and making sure, a lot of times I talk about, "Okay, let's not have carbohydrates by themselves." We always want our carb to have a buddy to have a protein or fat. So even if that's an apple, you know, can I have a little bit of peanut butter or a string cheese with that to balance that together? And just thinking of ways to incorporate protein and our fat. I think a lot of times it can be easy to overdo our carbohydrates. So just thinking about, "Okay, I just want to have one source of carbohydrate and I want it to be a healthy option." So, I don't think people need to be scared of fruit or our starchy vegetables or our whole grains. We always want to go for those as carbohydrates. But we do want to limit cookies, candy, regular soda, a lot of those more simple carbohydrates that aren't really giving us much nutrients or anything, and they're going to impact our blood sugar levels a lot. 

Host:

That's such great advice to really say things directly that people can use today. Like if you're going to eat a carbohydrate as something as healthy as an apple or a tomato or carrots or something, buddy up with a protein. Because that way you know your body is going to utilize them more efficiently. It's such great advice. As we wrap up, when we see our provider, what questions would you like them to ask their doctors? What would you like people to ask? And can it be prevented? Your best advice here, Gretchen, for lifestyle management and prevention altogether, so we don't have to do any of these things. 

Gretchen Johnson:

So, thinking about your provider or wanting to ask, I think, if you're having these multiple risk factors for prediabetes or even if it's just something that you're really concerned about asking them for an A1c when you come in. A lot of times they'll also do a fasting and that one's, you know, a little bit simpler lab, a little bit cheaper lab. And that fasting can also show us a little bit of how your blood sugar levels are running. So, I think really just asking them about that and then letting them know that, "Maybe I'm concerned about diabetes, it runs in the family. I'd really like to be proactive and start checking this," even if you haven't been diagnosed with prediabetes yet. I think it could be helpful just to start looking at it then. So for thinking about can it be prevented, we know that there are risk factors for prediabetes that can't be controlled: family history, your age, you know, we can't control how old we are. But there are risk factors that can be controlled, thinking about our activity level, thinking about our diet, what we're eating, our weight, our management of that, and even other things as simple as like smoking or kind of cutting out that regular soda. They're all things that we can control. And then that can be helpful in preventing those prediabetes. It's hard because, you know, it's not always a one-size-fits-all. But I think if we're practicing these healthy lifestyle changes, that's for sure going to help us to prevent a lot of health complications in the future. 

Host:

That's great advice. And it's certainly true. There are things that we can do and lifestyle management, as you said, and that is what you are doing at the Bryan Diabetes Center with people. So, I'd love to thank you, Gretchen, for joining us today. And I'd also like to thank our Bryan Foundation partner, Riverside Technologies. To listen to more podcasts from our experts, you can always visit bryanhealth.org/podcasts. And that wraps up this episode of Bryan Health Podcast. Please remember to subscribe, rate, and review Bryan Health Podcast on Apple Podcast, Spotify, iHeart, and Pandora. You know, share these shows with your friends 'cause we are learning from the experts at Bryan Health together. I'm Melanie Cole. Thank you so much for joining us.