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Scott Webb (Host): Prediabetes is an indication that a patient's blood sugar levels are higher than usual, but not high enough to be classified as type 2 diabetes. Prediabetes can have long-term effects, including damage to blood vessels, heart and kidneys. However, it is possible to halt the progression of prediabetes so that it doesn't become type 2 diabetes. Eating right, adding physical activity to your routine and maintaining a healthy weight, can help bring blood sugar levels back to normal.

And joining me today to discuss prediabetes is Dr. Tyler Feldman.

He's a board certified family doctor and diabetologist fellow with Franciscan position network.

This is the Franciscan Health Doc Pod. I'm Scott Webb. So, Dr. Feldman, it's so great to be on with you today. We're talking about prediabetes. So, let's do that. What does that mean exactly? What is prediabetes?

Tyler Feldman, DO (Guest): In simple terms, your blood sugar is elevated, but it's not elevated to the extent of what we would categorize as diabetes. But it's certainly not normal either. So, it's kind of in limbo. As far as actually diagnosing somebody with that that’s a pretty important definition to understand, but I don't think it gives significance to what prediabetes actually is. To kind of extend that question a little bit, the better question is, well, why is the blood sugar a little bit elevated?

And it's important to understand with prediabetes, the insulin is produced in an organ called the pancreas that lies underneath the stomach. The tail of the pancreas has beta cells or these islet cells, islet beta cells that produce insulin. However in type 2 diabetes and in prediabetes, there is resistance to insulin. So, your body is trying to pump out more insulin from the pancreas and the pancreas kind of gets burned out a little bit, so eventually it can't pump out enough insulin to offset the sugar in the blood. And there's already been studies, multiple studies showing that up to 80% of the functioning of the beta cells, which produce the insulin, are gone in prediabetes meaning that only 20% remain of these beta cells that are producing the insulin.

And it's just not enough to meet the demand. So, they still may be able to get their levels lower than diabetic range, but there is still a pathology. There's still a problem going on where, the supply does not meet the demand. So, I know that's kind of a long answer, but that's how I would define it.

Host: Yeah and you and I have had a chance to speak sort of off the air today, and you really made the point, and I know you want to drive this home for listeners that prediabetes, it is pre type 2 diabetes, but prediabetes in and of itself is a condition and it is worth being concerned about right?

Dr. Feldman: I would call it a disease in itself. There's been a lot of studies on prediabetes. The biggest one was called the Diabetes Prevention Program from late nineties to early two thousands. They had thousands of people in this study. And what they realized is that if someone was prediabetic in that study and three years went by in that study and they were still just prediabetic, almost 8% of those people had eye issues related to diabetes. That kind of issue is called retinopathy and that can lead to blindness. So, that's pretty scary. And I would say if that's happening at a prediabetes level, then I would define prediabetes, at least at the upper realms of prediabetes heading into diabetes is still a disease that causes medical problems.

Host: What I want to talk about now is the risk factors. Whether it's family history, race, weight, all the above, who's at the highest risk for prediabetes?

Dr. Feldman: Yeah, that's a great question because people should be thinking, you know, if I need to be screened for diabetes, do I have one of those risk factors? And a lot of people do. One would be, being overweight and that doesn't mean necessarily obesity, that just means being overweight. And how we define that is factoring in what your actual weight is versus your height. You get a BMI. And that BMI, if it's over 25 and above that's a risk factor. Other things is age. As you get older, your pancreas gets older too. It doesn't make as much insulin producing cells that will release this insulin. It has more trouble fighting insulin resistance.

So, as you get older and a lot of people would say over the age of 45, you're at higher risk, regardless of other risk factors. And other things that are our genetics beyond our control, a lot of different ethnicities, such as Hispanic, African-American, Native American, Asian-American these people have an increased risk just due to genetics, nothing that they can control. Hypertension, high blood pressure, that is very common, but also a risk factor, because that is also related to what we call metabolic syndrome, which is insulin resistance and many other abnormalities.

And that would also include abnormal indices on your cholesterol panels. Probably a lot of people will have their cholesterol checked, but there's a lot of different things on that cholesterol panel and one of them's triglycerides. And when that's elevated, that's a much higher risk as well as, HDL, which is the good cholesterol. If that's too low, because you want your good cholesterol high, if that's too low, that's also a genetic sign of a higher risk of prediabetes. And then, physical inactivity. A lot of people now with all the media and everything going on there, they're not getting as much exercise or not even walking as much.

That definitely leads to more insulin resistance. And one other thing about weight, because that's almost number one, besides genetics, it's not just being overweight, but even a higher risk factor is if you have a lot more belly weight, if your obesity is more centralized. And that classic example is a bigger belly and skinny legs, that's even higher risk than just being overweight in itself.

Host: Yeah. So, it sounds like there's kind of a mixed bag there, that there are things that are modifiable, right? Behavior, lifestyle. There are things that none of us can outrun really right? So, family history, age, race, ethnicity, and so on. So, for listeners, explain to them, one of the complications here is that there really aren't any symptoms. People don't know that they're prediabetic right?

Dr. Feldman: Yeah. And I think that's rather scary because most things as a doctor, you know, a lot of times we'll find things, but most of the time, we find a lot of things by asking patients about their history. What have they experienced symptom-wise and the truth of the matter is a lot of symptoms related to diabetes occur when you start urinating out sugar, because that'll make you dehydrated, make you feel weaker, make you feel more fatigued. But that doesn't happen until your blood sugar reaches a much higher level around 180. So, anything under that, you may be feeling fine, or at least at your baseline.

But that does not mean that you don't have prediabetes. And I think another thing, just kind of going back to what you said about risk factors, but really everyone's at risk. I kind of want to set that in too because you talk to three people in a room at least one person you talked to you probably has prediabetes. It's about 34% of the US right now has prediabetes. And if you look at the criteria like we were talking about with all these risk factors and when you should screen, at some point in someone's life, they're probably going to meet enough of those risk factors to be screened.

Host: Yeah, it does seem so like a number of things, whether it's high cholesterol or high blood pressure, or now we're talking about prediabetes, people are out there, people have these things they don't know, but they could know. And that's really one of the points we want to drive home today too, is the importance of getting your yearly checkups with your doctors, your physicals, with your doctors, being screened for these things. So, I wanted to have you spend some time discussing that. What are the screening tools, how is prediabetes diagnosed and really it's a fairly simple process, but people just need to initiate that, right? They need to advocate for themselves.

Dr. Feldman: Think of it kind of as an investment you pay a little money to get screened for diabetes, you'll probably save a lot more money if you don't develop it. So, I think that's an important thing, but going over the tests specifically, there are many tests actually you can do, but I'll just talk about a couple and the most common. One's called a fasting blood sugar, and that's not like a hardcore 24 hour fast, but kind of like before you get your labs to check your cholesterol night before you don't eat and then you can only have water after dinner. So, wake up in the morning, get the lab. That's going to show what your blood sugar is when you haven't had a meal.

And if it's a hundred or higher, that would indicate a level that is in the prediabetes range, but you should get a confirmatory test. So, you really should have two tests to be diagnosed with it. There are things like if someone's taking prednisone for a certain medical condition or other type of steroid, that can raise sugar artificially, so it is important to confirm. And then another very common test is called a hemoglobin A1C. I know it's pretty big word there, but really what it's doing is looking at is your average blood sugar over three months.

Host: What's the impact of having prediabetes and not being diagnosed?

Dr. Feldman: Good question. So, one is what we already mentioned kind of at the beginning of the podcast is there are already potentially pathological things occurring, which could cause disease in itself with prediabetes, such as retinopathy, which is that eye condition I was talking about. So, there's immediate risks, near future risks, which would be conversion to diabetes. And it really depends on patient population and risk factor, but within a three-year period, between 30 and 50%, I don't know the exact numbers, don't quote me on those, but a high number of people just depending on different risk factors, have a really high chance of converting to diabetes within a few years. So, getting on board with that early can actually prevent you from getting diabetes in the near future and even possibly in the distant future.

Once you're diagnosed with diabetes, one third of people with diabetes are going to get kidney disease and end-stage kidney disease is when you start thinking about dialysis, which is pretty scary. Blindness is a possibility, numbness and tingling, cause it also damages the nerves in the body. So, if you can't feel your feet, you step on something sharp, if you get an infection then sometimes it has to be amputated. So, diabetes is also one of the leading causes of lower limb amputation in the US.

So, all of these things are really scary and not to mention you have a two to three fold higher risk of heart attack and stroke. So, you know, some of the most common things people die of, and then things that could really hurt your quality of life go way up if you're diagnosed with diabetes, so you want to catch it early. And then one more thing I'd like to mention, the pancreas, just like a car or anything, gets worn out. So, in prediabetes, your pancreas is trying to pump out insulin so fast that eventually it gets really tired. Even if someone goes from prediabetes to diabetes, if they know they have prediabetes, and they work at trying to stop diabetes; even if they convert to diabetes, they have a better chance at not needing insulin for a longer period of time than someone who didn't do anything, and then they have very, very high blood sugars and worse control as a diabetic. Those are going to lead to actually needing long-term insulin daily earlier in life. So, I know people think probably taking shots daily is kind of scary, but that's a true reality.

Host: Yeah. And so you talked there about early diagnosis, the importance of that early therapies. What are the recommendations, behavior, lifestyle wise, exercise, eating habits, things like that. What are the recommendations to try to prevent prediabetes?

Tyler Feldman, DO (Guest): It's an easy one for us to prescribe, but a hard one to fulfill. And that is for us saying simply diet and exercise. It's easier for us to say than to actually do. What the data shows, and again, I was talking about this Diabetes Prevention Program Study and just very briefly, they looked at thousands of people and these people were prediabetic and they put people in different groups.

One group was the diet and exercise intensive group. And what they did is they tried to achieve a 7% weight loss and not all of them achieved that percent weight loss, but the goal was 7%. And they were asked to do moderate intensity exercise, which is like speed walking or more for 150 minutes a week. That sounds overwhelming, but 30 minutes, five times a week, and they had a 58% reduction in converting to diabetes in three years. So, you cut it by more than half your risk just by doing those two things. And then there's other hopeful things, as well as Metformin, a lot of people think about Metformin as, if they've heard of it, probably the first medication someone was put on when they're diabetic. But the American Diabetes Association, as well as many other societies also agree that Metformin is a good preventative med for diabetes. And in that study I was talking about, they had another group just taking Metformin and then just given general information on diet and exercise.

And they had a 30, I think it was 31, but low 30, some percent chance of actually converting, to diabetes in three years. So, those are hopeful interventions. Metformin is obviously easier to prescribe and actually fulfill then actually accomplishing the exercise goal. But if someone actually puts their mind to it and works for it, that study showed that exercise did more than Metformin by itself.

Host: You are just a wealth of information and I hate to cut you off here, but as we wrap up anything else you want people to know? What are your takeaways? How would you summarize prediabetes, type 2 diabetes? What we can do, what we can't do, the importance of early diagnosis and screening. I'm throwing a lot at you, but what would be your takeaways today?

Dr. Feldman: Well, it is that everyone at some point in life should be screened for prediabetes. The American Diabetes Association says, if you're over 45 years old without any other risk factors that you should be screened. So, if you're listening to this and you're over 45, and you've never been screened for diabetes, it's time to get into the clinic and get checked, to make sure that you don't have the risk to convert to diabetes. Prediabetes can have some risk associations with retinopathy and these other things we talked about, but once you convert to diabetes, almost every organ you can think about could be damaged by diabetes.

It's really important to try to prevent that. That's kind of the heart of family medicine is trying to prevent. We can manage diseases and try to prolong quality of life and longevity, but it's a lot more satisfying and will lead to a better quality of life for the patient if we can actually prevent the disease entirely. As we talked about earlier in the podcast, obesity, inactivity, these kinds of other risk factors, even if you're thinking you're living a very healthy life, but you realize you have some of these risk factors, checking with your doctor and seeing if screening for diabetes would be appropriate for you. And then also knowing that there's hope that even though all this stuff can sound pretty scary, you can really reverse the pathologic processes of metabolic syndrome and insulin resistance, by exercising and by portion sizing, dieting, if overweight, trying to lose 7%, you know, these are very doable things. I think importantly, first is just getting in to be screened for it. I think those are the major points.

Host: Great podcast today, Doctor, thank you so much. And you stay well.

Dr. Feldman: I appreciate it. You take care.

Host: For more information, go to Franciscanhealth.org and search diabetes. And if you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.