Caitlin Whyte (Host): Welcome to WakeMed Voices, the podcast where we tune up your health by delving into essential health and wellness topics with WakeMed experts.

I'm your host, Caitlin Whyte. Today, we're thrilled to welcome Dr. Michael Soboeiro to the show, a WakeMed primary care physician. He brings a wealth of knowledge in diabetes, obesity, and cardiovascular risk reduction, and is here to discuss the crucial topic of pre-diabetes. First Doctor, can you define insulin resistance, pre-diabetes and Type 2 diabetes for us?

Michael Soboeiro, MD: Absolutely. So that is actually the progression that we see that leads to pre-diabetes and diabetes, and it all starts with insulin resistance. And you know what insulin resistance is, is it's the body becoming resistant to insulin. I mean that, you know, makes sense. We have genetics that are very strong in our population that cause insulin resistance, and then lifestyle added to genetics certainly contributes to insulin resistance.

So when you add the genetics to our sedentary lifestyle and our propensity to eat more carbohydrates and simple carbohydrates and processed food, you get high levels of insulin resistance in the population. And the best way to explain how it works is a person who is not insulin resistant can survive on about 20 units of insulin a day that their pancreas makes and have their blood sugars completely perfect. When one starts to get insulin resistant, what happens is one starts producing more insulin to keep their blood sugar controlled. So they make 25, then they make 30, then they make 35, and their blood sugar stays well controlled. At some point, the body can't keep up so it can't keep making more and more insulin, and that's when the blood sugar goes up and that's when somebody develops pre-diabetes. So the definition of pre-diabetes is to have a fasting blood glucose of 100 to 125 or a hemoglobin A1C, which is your average blood glucose over three months of 5.7 to 6.4.

But what that really means is the blood sugar is starting to go up, so the body cannot make enough insulin to control blood sugar anymore. And then the sort of ultimate downstream effect of that is, is full-blown diabetes, which is when the blood sugar goes higher than that. So that's a fasting blood sugar of greater than 125 or hemoglobin A1C of 6.5 or greater.

Host: Great. And then can you tell us what is the prevalence of pre-diabetes and some risk factors we can look out for? 

Michael Soboeiro, MD: This is why I think this is really important information because the prevalence of pre-diabetes is astounding. So in 2021, which is the last year that we have good numbers, 97.6 million U.S. people had pre-diabetes. That's one out of three Americans or 38% of US adults. So, so that's just an astounding number. 

At that time in 2021, 20% of adults were aware of having pre-diabetes. Same year, 2021, 38.4 million U.S. Adults had diabetes. That's 11.6% of the population, or 14.7% of adults. But about 78% of people were aware of that. So I think in 2025 we'd be very comfortable saying that more than 100 million of our population have pre-diabetes.

Host: Well, how important then is early detection and what are some common tests there?

Michael Soboeiro, MD: The point I was making earlier about insulin resistance is that pre-diabetes is really not an early condition. Somebody has been insulin resistant for years before they develop pre-diabetes. And what we really need is an insulin resistant test to tell people how insulin resistant they are, even before they develop pre-diabetes.

But we don't have that right now. And so I think early detection of pre-diabetes is really important, because once one develops pre-diabetes, we know that one has been insulin resistant for a while, but there's still an opportunity to intervene and to improve that. So, how does one get diagnosed?

One goes to their provider and has a fasting glucose test or a hemoglobin A1C test. There is a third way to get diagnosed, which is an oral glucose tolerance test. We typically use those in pregnant women. For non-pregnant individuals, it's the fasting glucose and the A1C and specifically the A1C, which is the most sensitive test to look for pre-diabetes. 

Host: And what about the cardiovascular risk of pre-diabetes? What should we know there? 

Michael Soboeiro, MD: I think this gets to the most important part of this whole thing. People who have pre-diabetes and diabetes have both microvascular disease and macrovascular disease. Microvascular disease, as it says is the effects on small blood vessels, and this happens when the blood sugar rises.

When the blood sugar rises, flow through these tiny little vessels is impaired. And so what happens with that is the organs that have tiny little blood vessels are affected. So this is why diabetics have eye disease and blindness, kidney disease, and end stage renal disease or neuropathy or nerve damage because those are the organs that have these little blood vessels.

But the problem there is elevated blood sugar, and that's why we see microvascular disease mostly in people with full-blown diabetes. And the worse the control of diabetes, the more the microvascular disease. Now, macrovascular disease means, the rupture of fatty plaques in large vessels, and that happens in the heart when you get a rupture of a fatty plaque and a, and a cardiac vessel, that's what a heart attack is. When you get a rupture of a fatty plaque in the brain, that's what a stroke is. So macrovascular disease has a completely different pathology, and the pathology there is inflammation. When we have these fatty plaques that get inflamed, that's what causes plaque rupture, and that's what causes cardiovascular events and here's the real kicker. Macrovascular disease occurs both in pre-diabetes and in diabetes. So pre-diabetics are really just as at risk for macrovascular disease as diabetics are, and that's why we need to identify pre-diabetes, and that's why we need to intervene on pre-diabetes because the heart attack risk and the stroke risk is there even before you become diabetic.

Host: Well, what would you say is the role of primary care providers in determining and managing pre-diabetes?

Michael Soboeiro, MD: So I think the primary care provider is key because these are typically conditions, especially pre-diabetes, that are diagnosed before people know what's wrong. So people aren't going to specialists, they're not going to endocrinologists or cardiologists with these concerns. They're going to their primary provider to get, you know, basic testing.

Maybe a yearly physical, maybe they feel bad for some reason, and that's when they're going to have a glucose test or an A1C test, and that's when they're going to find out about pre-diabetes and that's when you know, one can intervene. And so I think the primary provider can be very helpful on diagnosing pre-diabetes and then helping the patient to say, okay, what can I do to make this better, to intervene, to decrease my risk?

Host: Now I know lifestyle changes are important here Doctor. Tell us about what we can change if we are pre-diabetic.

Michael Soboeiro, MD: Right. So lifestyle is huge. One can make oneself much less insulin resistant with lifestyle. Now how do you do that? You lose weight, you decrease the amount of carbohydrates in the diet and you exercise. All of those things individually, decrease insulin resistance, so decrease the prevalence of prediabetes.

And then together, they work really well. Think about this, when one eats a lot of simple carbohydrates, so let's say one goes to a coffee shop and gets a latte and a croissant, that shoots the blood sugar up, which shoots the insulin up, which contributes to more insulin resistance. So if one can avoid those simple carbs, specifically unopposed simple carbs, meaning simple carbs, eaten without protein, without fat.

If one can avoid, that, one can decrease insulin resistance. Exercise does the same and weight loss does the same. And I'll, I'll throw out one statistic that came from a study, 6% weight loss decreases the chances that a pre-diabetic becomes diabetic by 75%. So if a 200 pound individual loses 12 pounds, decreases the chance of becoming diabetic by 75%. 

Host: And what about medication for treatment? Tell us about that. 

Michael Soboeiro, MD: So this is really interesting. There's only one medication that is approved for treatment of pre-diabetes, and that's metformin. Metformin is a drug that's been around for more than 50 years. It is a very safe drug. It's inexpensive. But in reality, it is not the best pre-diabetes drug that we have.

What Metformin does is it decreases glucose production in the liver, which is a wonderful thing, but it doesn't really get at insulin resistance, and weight loss and inflammation. Now we have a new set of drugs called the GLP-1 receptor agonists, and they've made a big splash. And people know about them because they're, they're good diabetes drugs, they're good weight loss drugs, and they're marketed for weight loss.

But they are excellent pre-diabetes drugs because they decrease insulin resistance. They lead to weight loss. And, and this decreases risk. And there actually are studies out there that show that these GLP-1 receptor agonists decrease the risk of heart attacks and strokes in patients who are not diabetic.

So these are wonderful drugs for pre-diabetes. The only problem is they're expensive and they haven't been approved for pre-diabetes. Not necessarily because they're unsafe, but because they're expensive drugs and, and you can imagine what an expensive drug like this given to a hundred million people would cost. 

Host: And what can we do to prevent that progression to Type 2 diabetes and cardiovascular disease? Why is that so important? 

Michael Soboeiro, MD: It's super important because obviously we don't want people to have heart attacks and strokes, which can be devastating, which can be life changing. So, you know, what we can do is a number of things that, that I've alluded to. You know, first of all, we can diagnose people early.

We can inform them what pre-diabetes means and we can inform them what steps they can take to decrease their risk, specifically by changing their diet, by exercising more, and by losing weight if weight is an issue. There are also, you know, pharmacotherapies that we can use, that I alluded to that can help with weight loss, decrease inflammation, decrease cardiovascular risk, and decrease the chances for a pre-diabetic to become diabetic. 

Host: And to wrap up our conversation today, Doctor, what are some common myths you hear about pre-diabetes that you'd like to debunk right here?

Michael Soboeiro, MD: Well, I think the biggest myth really is that this is some early condition. It, it is not an early condition. We think that most people who develop pre-diabetes have been insulin resistant for 10 or 15 years. And again, that leads to why I think we need a test of insulin resistance that we can give people early in life so they know what their risk of developing pre-diabetes or diabetes is. But you know, by the time someone's diagnosed with pre-diabetes, they've had insulin resistance for years and it's now leading to their blood sugar increasing. So, so this is not an early condition. It's a late condition. It is one we can intervene on, but it, it's not the tip of the iceberg. It's well into the, the process here.  

Host: Thank you so much, Doctor for this engaging episode. It was great to have you with us. And thank you for listening. I'm Caitlyn Whyte with WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. For more information about Wake Med Primary Care and how we can support your health journey, visit wakemed.org.