|
| A) | 71% | ||
| B) | 15.4% | ||
| C) | 38.0% | ||
| D) | 50.5% |
Prediabetes is a remarkably common health problem that has been vastly underdiagnosed. The Centers for Disease Control and Prevention (CDC) estimate that 38% of the adult population in the United States has prediabetes, with 48.8% of adults 65 years of age and older having blood glucose values that meet the criteria [3]. About one in five adolescents and one in four young adults (19 to 34 years of age) in the United States has prediabetes [4]. In spite of the high prevalence of prediabetes, only 19% of people with this condition are told of their diagnosis [3].
| A) | It can cause early onset of retinopathy. | ||
| B) | It can rapidly progress to acute hyperglycemia. | ||
| C) | It is associated with decreased risk for neuropathy. | ||
| D) | It makes the person twice as likely to develop type 2 diabetes. |
Although it is underdiagnosed, prediabetes is a serious condition that significantly increases the risk for major health problems. People with prediabetes are approximately 5 to 15 times more likely to develop diabetes than those who have normal blood glucose levels [5]. Furthermore, the harmful effects of high blood glucose begin to occur at much lower levels than currently define diabetes. In other words, complications of diabetes begin early in the course of glucose intolerance, often before diabetes is diagnosed. Studies suggest that when blood glucose is higher than normal and remains untreated, patients have a greater risk for developing the microvascular and macrovascular complications associated with diabetes [6,7,8]. For example, characteristics of diabetic retinopathy may be detected in people with no history of diabetes who have elevated fasting blood glucose or impaired glucose tolerance (IGT) [9]. Impaired glucose tolerance is also common in nondiabetic patients with peripheral neuropathy [10]. This data emphasize the importance of prompt detection and intervention of prediabetes. In fact, research suggests that restoring blood glucose levels to normal, rather than maintaining prediabetic levels, is necessary to prevent complications [7,8]. When preventive efforts delay the onset of diabetes, there is less disease exposure and lower risk for the adverse consequences of high blood glucose over time. This results in better quality of life for the individual and lower healthcare costs for society.
| A) | Less than 50 mg/dL | ||
| B) | Less than 70 mg/dL | ||
| C) | Less than 100 mg/dL | ||
| D) | Less than 120 mg/dL |
There are many tests available to assess patients suspected of having diabetes or prediabetes. These include [13]:
Fasting plasma glucose (FPG): Blood is collected after the patient has had no dietary intake for eight hours or more. Normal fasting plasma glucose is less than 100 mg/dL.
Casual plasma glucose: This is sometimes referred to as "random" or nonfasting blood glucose, as blood is collected without regard to the time of last caloric intake.
Oral glucose tolerance test (OGTT): Blood is taken two hours after the person has ingested a glucose load of 75 grams. This is also known as a "glucose challenge." Normal nonfasting plasma glucose taken two hours following glucose challenge is less than 140 mg/dL.
Hemoglobin A1c (A1c): This laboratory test uses venous blood to show the average blood glucose concentration over the previous two to three months. The test measures the amount of glucose that is chemically attached to the red blood cells (RBCs). RBCs that have been exposed to high amounts of glucose over their lifespan, which is about 90 days, will have more glucose attached to them. This will result in a higher A1c reading. A1c levels greater than 7.0% are associated with an increased risk for eye, kidney, and nerve damage and cardiovascular disease. Historically, A1c was not used as a test for the diagnosis of diabetes or prediabetes. However, in 2010 the ADA revised its criteria for the diagnosis of diabetes to include use of A1c for diagnosis. A1c of less than 5.7% is considered normal.
| A) | Hemoglobin A1c | ||
| B) | Fasting blood glucose | ||
| C) | Casual plasma glucose | ||
| D) | Oral glucose tolerance test (OGTT) |
There are many tests available to assess patients suspected of having diabetes or prediabetes. These include [13]:
Fasting plasma glucose (FPG): Blood is collected after the patient has had no dietary intake for eight hours or more. Normal fasting plasma glucose is less than 100 mg/dL.
Casual plasma glucose: This is sometimes referred to as "random" or nonfasting blood glucose, as blood is collected without regard to the time of last caloric intake.
Oral glucose tolerance test (OGTT): Blood is taken two hours after the person has ingested a glucose load of 75 grams. This is also known as a "glucose challenge." Normal nonfasting plasma glucose taken two hours following glucose challenge is less than 140 mg/dL.
Hemoglobin A1c (A1c): This laboratory test uses venous blood to show the average blood glucose concentration over the previous two to three months. The test measures the amount of glucose that is chemically attached to the red blood cells (RBCs). RBCs that have been exposed to high amounts of glucose over their lifespan, which is about 90 days, will have more glucose attached to them. This will result in a higher A1c reading. A1c levels greater than 7.0% are associated with an increased risk for eye, kidney, and nerve damage and cardiovascular disease. Historically, A1c was not used as a test for the diagnosis of diabetes or prediabetes. However, in 2010 the ADA revised its criteria for the diagnosis of diabetes to include use of A1c for diagnosis. A1c of less than 5.7% is considered normal.
| A) | A1c greater than or equal to 5.7% | ||
| B) | Fasting plasma glucose of 126 mg/dL or greater | ||
| C) | Oral glucose tolerance test result of 150 mg/dL or greater | ||
| D) | Casual or random plasma glucose 140 mg/dL or greater accompanied by symptoms of hyperglycemia |
A diagnosis of diabetes is established when a person has any or all of the following blood glucose values [13]:
FPG: 126 mg/dL or greater
Casual or random plasma glucose: 200 mg/dL or greater accompanied by symptoms of hyperglycemia, (i.e., polyuria, polydipsia, and/or unexplained weight loss)
OGTT: 200 mg/dL or greater
A1c: Greater than or equal to 6.5%
| A) | 70 mg/dL. | ||
| B) | 102 mg/dL. | ||
| C) | 162 mg/dL. | ||
| D) | 240 mg/dL. |
Evidence suggests that the microvascular damage from high blood glucose begins early in the progression from normal glucose tolerance to frank diabetes. Studies of people with prediabetes indicate that risk for retinopathy, nephropathy, and neuropathy are all increased [6]. Retinal microaneurysms and microalbuminuria, the hallmarks of diabetic retinopathy and nephropathy respectively, have been detected in a significant number of nondiabetic people with IGT [9]. IGT is common in patients with peripheral neuropathy, and a causal relationship has been assumed, though not adequately studied. The risk for retinopathy and nephropathy may begin to increase when two-hour postprandial blood glucose levels reach 162 mg/dL [10].
| A) | White race | ||
| B) | Age younger than 30 years | ||
| C) | A family history of diabetes | ||
| D) | High-density lipoprotein (HDL) cholesterol greater than 40 mg/dL |
Risk factors for diabetes and prediabetes include [6]:
Family history of diabetes (in a parent, brother, or sister)
Previously identified as having IGT, IFG, and/or metabolic syndrome
Belonging to certain racial and ethnic groups, including non-Hispanic Black Americans, Hispanic/Latino Americans, Asian Americans, Pacific Islanders, American Indians, and Alaska Natives
History of gestational diabetes
Women who have delivered a baby weighing 9 pounds or more
Polycystic ovary syndrome (PCOS)
Overweight
Sedentary lifestyle
High blood pressure (140/90 mm Hg or more) or being treated for high blood pressure
HDL cholesterol less than 35 mg/dL
Triglyceride level greater than 250 mg/dL
A history of cardiovascular disease
Receiving antipsychotic therapy for schizophrenia or bipolar disorder
| A) | excessive insulin secretion by the pancreas. | ||
| B) | insufficient insulin secretion by the pancreas. | ||
| C) | inappropriate glucose production by the liver. | ||
| D) | impairment of the body's ability to utilize available insulin. |
Insulin resistance, or the impairment of the body to effectively utilize available insulin, is the hallmark of both metabolic syndrome and type 2 diabetes. In people with early stage type 2 diabetes, insulin resistance reduces glucose uptake by 35% to 40%. With insulin resistance, the pancreas may produce normal or greater than normal amounts of insulin, but receptor sites for it are not available. For some people, the pancreas is temporarily able to make enough additional insulin to overcome the insulin resistance and produce normal blood glucose levels. Hyperinsulinemia is usually the case in early stages of type 2 diabetes and is associated with macrovascular risk factors of the metabolic syndrome, such as dyslipidemia and hypertension. High levels of insulin in the blood increase sympathetic activity that can raise blood pressure.
| A) | Retinopathy | ||
| B) | Nephropathy | ||
| C) | Coronary artery disease | ||
| D) | All of the above |
The chronic complications of diabetes have an immense effect on the healthcare system, society, and the individual. While the economic costs of diabetic complications are enormous, their affect upon quality of life for the individual and family can be equally devastating. The CDC reports the impact of chronic complications upon Americans with diabetes as [3]:
Leading cause of adult-onset blindness
Leading cause of end-stage renal disease
Significant morbidity and disability due to foot ulcer and lower extremity amputation
Increased risk for cardiovascular disease
Significantly increased risk for nerve disease, periodontal disease, and a host of other health problems
| A) | a 2% reduction in hemoglobin A1c levels. | ||
| B) | a 3- to 5-inch reduction in waist circumference. | ||
| C) | improvements in triglyceride and HDL cholesterol levels. | ||
| D) | lifestyle changes that resulted in a 5% to 7% body weight reduction. |
The DPP was a landmark study on the prevention of diabetes. The results, published in the New England Journal of Medicine in 2002, reported that diabetes could be prevented or delayed in people with IFG and IGT [2]. Using subjects with prediabetes who were overweight, the study compared the results of treatment with the diabetes medication metformin versus lifestyle changes that led to weight loss. Importantly, the DPP showed that the greatest reduction in diabetes risk was associated with lifestyle changes that resulted in a 5% to 7% loss of body weight. Ten-year follow-up of DPP subjects has shown that diet and exercise, resulting in weight loss, could keep diabetes at bay for at least a decade in those at high risk [34].
| A) | 25 to 44 years of age. | ||
| B) | older than 60 years of age. | ||
| C) | less than 50 pounds overweight. | ||
| D) | not engaged in lifestyle changes. |
The results of the DPP also showed that diabetes could be prevented with the use of metformin in people with prediabetes, with risk reduction of about 31% [35]. Risk reduction with use of metformin was found to be most effective for people 25 to 44 years of age and in those who had a body mass index of 35 or higher [35]. After 10 years, the incidence of type 2 diabetes was decreased by 18% in the metformin group as compared to placebo [34].
| A) | Limit salt intake to 2,300 mg/day. | ||
| B) | Avoid eating meats and dairy products. | ||
| C) | Limit food high in saturated fat, trans fatty acids, and cholesterol. | ||
| D) | Limit alcohol intake to not more than two drinks per day for men and one drink per day for women. |
General evidence-based dietary guidelines for the prevention and treatment of diabetes are to:
Consume a variety of foods, including fruits, vegetables, grains, low-fat and fat-free dairy products, and lean meats.
Limit food high in saturated fat, trans fatty acids, and cholesterol. Emphasize fruits, vegetables, and low-fat dairy products.
Limit salt intake to 2,300 mg/day.
Limit alcohol to no more than two drinks per day for men and one drink per day for women in people who choose to drink alcohol.
| A) | 0.5 to 1 pound every two weeks. | ||
| B) | 1 to 2 pounds per week. | ||
| C) | 2 to 4 pounds per week. | ||
| D) | 5 or more pounds per week. |
Reducing calories and increasing physical activity are the cornerstones of healthy weight loss [51]. Successful weight management to improve overall health requires a lifelong commitment to a healthful lifestyle that emphasizes sustainable and enjoyable eating practices and daily physical activity [49,51]. For safe weight loss, the Academy of Nutrition and Dietetics and the ADA recommend a reduction of 500 to 1,000 calories per day to achieve a target weight-loss rate of 1 to 2 pounds per week [51].
| A) | 34 inches in men and women. | ||
| B) | 35 inches in men and greater than 30 inches in women. | ||
| C) | 37 inches in men and women. | ||
| D) | 40 inches in men and greater than 35inches in women. |
Excess waist circumference with associated health risk is identified as greater than 40 inches in men or greater than 35 inches in nonpregnant women [57]. The proper way to measure abdominal circumference is to place a tape measure around the bare abdomen, just above the hipbone. The tape should be parallel to the floor and snug, but not compressing the skin. Instruct the patient to exhale and relax for the measurement [57].
| A) | Use larger plates, bowls, and utensils. | ||
| B) | Avoid eating directly out of a bag or bowl. | ||
| C) | Weigh and measure foods to ensure appropriate serving size. | ||
| D) | Practice the "plate method" of portion control (i.e., using a plate with portion dividers). |
Studies indicate that portion control is a valid component of a healthy and effective weight loss plan. Based on these studies, the Academy of Nutrition and Dietetics recommends that portion control be integrated into the weight-loss plan. To help patients with portion control, advise them to [61]:
Read Nutrition Facts labels to identify appropriate serving sizes.
Eat from a plate, not a package. Avoid eating directly out of a bag or bowl. Put one serving on a plate or dish.
Try portioning out foods with measuring cups and spoons to get an idea of what the serving size looks like (Table 1). Compare these serving sizes to the sizes of everyday objects (Table 2).
Use smaller plates, bowls, and utensils for eating.
Be aware of large serving sizes in restaurants. Place half of a large portion in a take-home container before starting the meal or share an entree with another person.
Practice the "plate method" of portion control.
| A) | whenever hungry. | ||
| B) | at least every 2 to 3 hours during waking hours. | ||
| C) | small meals at regular intervals. | ||
| D) | at most every 6 hours during waking hours. |
The Academy of Nutrition and Dietetics recommends that for weight loss and maintenance a registered dietician nutritionist "should individualize the meal pattern to distribute calories at meals and snacks throughout the day, including breakfast" [51]. Earlier recommendations maintained that eating small meals at regular intervals (four to six meals/snacks per day) could help maintain glucose levels; however, recent studies have not shown that higher eating frequency produces greater weight loss, and, for some, three meals per day leads to a significant reduction in A1c, appetite, and overall glycemia, with a decrease in daily insulin and improved glucose metabolism [51,66,67]. The most important counseling strategy is to help the person find a meal pattern that prevents times of heightened hunger, particularly in situations in which high-calorie food choices are readily available. For example, helping the patient plan healthy sack lunches and snacks may prevent overeating at vending machines or fast food establishments during working hours. Consuming a greater proportion of calories early in the day, as opposed to in the evening, may also prove to be beneficial to patients' weight loss goals [51].
| A) | total fat content. | ||
| B) | number of calories. | ||
| C) | serving size and servings per package. | ||
| D) | percent daily values of various vitamins and minerals. |
Instruct patients to consider the following when reading Nutrition Facts labels [74,76]:
Check the serving size (the amount typically eaten at one time) and the number of servings per package. Compare your individualized portion size to the serving size. If the label indicates a serving size of one cup and you eat two, you are consuming twice the calories, fat, and other nutrients than that listed on the label.
Note the number of calories in a single serving. Compare calories and fat grams per serving among different products and choose foods that are lower in fat and calorie content per serving. Understand nutrition terms (Table 3).
Let percent of Daily Values be a guide to assess how a particular food fits into your daily meal plan. A Daily Value of 5% or less is low; 20% or more is high. Percent of Daily Values is for an entire day, not just one meal or snack, and are average levels of nutrients for someone consuming 2,000 calories/day, which may be more or less than you need.
Choose foods that are low percentage Daily Values in saturated fat, "added sugars," and sodium to reduce your risk of chronic disease. The recommended daily intake of sodium is 2,300–2,400 mg or less (with 2,000 mg or less often recommended for people with certain cardiac conditions). Aim for entrees with less than 600 mg sodium per serving, side dishes with less than 400 mg, and snacks with a maximum of 200 mg of sodium per serving.
Avoid foods that list trans fat on the label. Trans fats originate from the process of hydrogenating oil. The goal is to consume zero trans fats.
Aim for foods with high percentage Daily Values of fiber, potassium, vitamin D, calcium, and iron, and include foods with more of these nutrients in your daily meal plan.
Understand the additional nutrients (e.g., protein, carbohydrates, sugars). Eat these foods in moderation. A daily percentage Daily Values for protein is not required on the label. Carbohydrates include sugars, starches, and fiber. Fiber is beneficial for weight loss and blood glucose control. A product is considered a good source of fiber if it has 2.5–4.9 g fiber/serving. Foods can officially be labeled "high fiber" if they contain at least 5 g fiber/serving. Whole-grain breads, grains, and rice are the healthiest choice. Total sugars includes those naturally present in many nutritious foods and beverages (e.g., milk, fruit)."Added sugars" are added during the processing of foods. Avoid foods containing high amounts of added sugars.
Ingredients are listed in order from most to least. Highly processed foods usually have a long list of ingredients; healthier choices often have shorter ingredient lists.
| A) | 1,000 calories. | ||
| B) | 1,500 calories. | ||
| C) | 1,750 calories. | ||
| D) | 2,000 calories. |
Instruct patients to consider the following when reading Nutrition Facts labels [74,76]:
Check the serving size (the amount typically eaten at one time) and the number of servings per package. Compare your individualized portion size to the serving size. If the label indicates a serving size of one cup and you eat two, you are consuming twice the calories, fat, and other nutrients than that listed on the label.
Note the number of calories in a single serving. Compare calories and fat grams per serving among different products and choose foods that are lower in fat and calorie content per serving. Understand nutrition terms (Table 3).
Let percent of Daily Values be a guide to assess how a particular food fits into your daily meal plan. A Daily Value of 5% or less is low; 20% or more is high. Percent of Daily Values is for an entire day, not just one meal or snack, and are average levels of nutrients for someone consuming 2,000 calories/day, which may be more or less than you need.
Choose foods that are low percentage Daily Values in saturated fat, "added sugars," and sodium to reduce your risk of chronic disease. The recommended daily intake of sodium is 2,300–2,400 mg or less (with 2,000 mg or less often recommended for people with certain cardiac conditions). Aim for entrees with less than 600 mg sodium per serving, side dishes with less than 400 mg, and snacks with a maximum of 200 mg of sodium per serving.
Avoid foods that list trans fat on the label. Trans fats originate from the process of hydrogenating oil. The goal is to consume zero trans fats.
Aim for foods with high percentage Daily Values of fiber, potassium, vitamin D, calcium, and iron, and include foods with more of these nutrients in your daily meal plan.
Understand the additional nutrients (e.g., protein, carbohydrates, sugars). Eat these foods in moderation. A daily percentage Daily Values for protein is not required on the label. Carbohydrates include sugars, starches, and fiber. Fiber is beneficial for weight loss and blood glucose control. A product is considered a good source of fiber if it has 2.5–4.9 g fiber/serving. Foods can officially be labeled "high fiber" if they contain at least 5 g fiber/serving. Whole-grain breads, grains, and rice are the healthiest choice. Total sugars includes those naturally present in many nutritious foods and beverages (e.g., milk, fruit)."Added sugars" are added during the processing of foods. Avoid foods containing high amounts of added sugars.
Ingredients are listed in order from most to least. Highly processed foods usually have a long list of ingredients; healthier choices often have shorter ingredient lists.
| A) | Poultry | ||
| B) | Walnuts | ||
| C) | Olive oil | ||
| D) | Fatty fishes, such as salmon |
Polyunsaturated fatty acids, such as omega-3 fatty acids, improve insulin sensitivity and may help reduce risk for cardiovascular disease by reducing triglycerides, increasing HDL cholesterol, and lowering blood pressure [21]. Good sources include salmon, sardines, herring, trout, and other fatty fish, as well as fish oil supplements. The ADA recommends an eating plan that is rich in monounsaturated and polyunsaturated fats to improve glucose metabolism [13]. Dietary guidelines recommend consuming at least two servings of non-fried fatty fish per week [68]. Linolenic acid is another type of polyunsaturated fatty acid and one of the three main omega-3 fatty acids that is believed to decrease blood clotting and inflammatory processes in the body. Because it cannot be synthesized by humans, it is considered essential in the diet [60]. Primary sources are canola oil, soybean oil, walnuts, flaxseed, and olive oil. Keep in mind that unsaturated fats contain the same amount of calories as saturated fat and that the diet should consist of no more than 10% of calories from fat [60].
| A) | have a history of asthma. | ||
| B) | are older than 40 years of age. | ||
| C) | have a body mass index greater than 30. | ||
| D) | have symptoms of microvascular complications. |
Pre-exercise medical clearance is not necessary for asymptomatic individuals receiving diabetes care consistent with guidelines who wish to begin low- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. Individuals who plan to increase their exercise intensity or who meet certain higher-risk criteria may benefit from referral to a healthcare provider for a checkup and possible exercise stress test before starting such activities [88].
| A) | 60 minutes of moderate intensity aerobic activity five or more days per week | ||
| B) | 75 minutes of moderate-to-vigorous intensity aerobic activity per week | ||
| C) | 150 minutes of moderate-to-vigorous intensity aerobic activity per week | ||
| D) | 300 minutes of moderate-to-vigorous intensity aerobic activity per week |
As noted, for the prevention of type 2 diabetes, the ADA recommends a minimum of 150 minutes of moderate-to-vigorous intensity aerobic activity per week, along with a healthful diet and modest calorie restriction. Aerobic exercise is defined as "rhythmic, repeated, and continuous movements of the same large muscle groups for at least 10 minutes at a time" [37]. Examples include walking, bicycling, dancing, water aerobics, and many sports [37]. Because the effect of exercise on insulin sensitivity does not last longer than 72 hours, patients will experience the most benefit to blood glucose if aerobic sessions are no more than two days apart [37,89].
| A) | Weight lifting | ||
| B) | Walking briskly | ||
| C) | Stationary bike riding | ||
| D) | Cross-country distance running |
Experts recommend resistance exercise be a component of the complete fitness program for healthy adults. Resistance exercise is defined as, "activities that use muscular strength to move a weight or work against a resistive load" [37]. Examples include weightlifting, working with resistance bands, and using weight machines.
| A) | Exercising alone | ||
| B) | Setting realistic goals | ||
| C) | Setting and sticking to a schedule | ||
| D) | Identifying alternatives to reduce boredom |
It is also important to help patients select a program that will have the greatest chance for long-term maintenance. The ACSM has identified factors that influence maintenance of exercise behavior [89]:
Setting realistic goals
Setting an exercise schedule in advance and sticking to it
Using an exercise partner
Encouraging self-rewards
Identifying alternatives to reduce boredom
Accepting off days and being able to return to the program after backsliding
| A) | Scheduling exercise | ||
| B) | Waking earlier to exercise | ||
| C) | Including exercise in a regular daily routine | ||
| D) | All of the above |
After barriers to exercise have been identified, steps can be taken to help patients overcome them. For each barrier, ask the patient what he or she thinks could help; this will allow the patient to be actively involved in resolving the barriers. Then, provide suggestions to supplement the patient's problem-solving activity. Common barriers to exercise and suggestions for helping patients overcome them include:
Not enough time: Strategies may include scheduling time for exercise, walking on lunch break, waking 30 minutes earlier, and/or including exercise in the regular daily routine, such as on the way home from work.
Too out of shape: Suggest starting slowly and gradually increasing both duration and intensity of exercise. Explore the feasibility of using a pedometer, and reinforce that even a little bit of activity is better than none at all.
Too tired: Propose exercising at times of day when energy level is higher. Educate that many people feel more energetic overall when they are active on a regular basis.
Not motivated: Recommend getting social support and/or finding an exercise partner. Ask the patient to identify what would help him or her get and stay motivated. Explore which types of activities would be most appealing.
| A) | Gardening | ||
| B) | Workout video | ||
| C) | Home exercise equipment | ||
| D) | Treading water while talking |
The dominant theory describes a five-factor model that accounts for a majority of individual differences between people based on five personality traits and correlated exercise program considerations [100]:
Neuroticism (emotionally unstable, anxious, self-conscious): Best suited to exercise that provides short-term, realistic goals. Focus on psychological benefits of regular exercise.
Extraversion (tends to be sociable, assertive, energetic): Prefers highly social environments (group classes). Emphasize recovery for these individuals who tend to overexert themselves.
Openness (perceptive, creative, reflective, generous): Prefers outdoor activities that encourage adventure (e.g., hiking, rock climbing). Variety and autonomy in self-selecting exercise improves adherence.
Agreeableness (kind, cooperative, altruistic, trustworthy): Typically cooperative with exercise programs. May benefit from motivational interviewing to understand exercise preferences.
Conscientiousness (ordered, dutiful, self-disciplined, achievement oriented): Prefers high-intensity exercise sessions. Good at planning out personal short- and long-term goals. Likely enjoys logging personal performance data.
| A) | Orlistat | ||
| B) | Glucagon | ||
| C) | Metformin | ||
| D) | None of the above |
As of 2023, no drug is approved by the FDA to prevent diabetes or treat insulin resistance. However, the ADA recommends that metformin therapy be considered for the prevention of diabetes in certain patients, including [13]:
Those with prediabetes, especially with BMI ≥35
Those younger than 60 years of age
Women with prior gestational diabetes
| A) | low body mass index. | ||
| B) | age older than 60 years. | ||
| C) | a family history of diabetes with no other risk factors. | ||
| D) | patients with prediabetes (especially with BMI 35 or greater), patients younger than 60 years of age, and women with prior gestational diabetes. |
As of 2023, no drug is approved by the FDA to prevent diabetes or treat insulin resistance. However, the ADA recommends that metformin therapy be considered for the prevention of diabetes in certain patients, including [13]:
Those with prediabetes, especially with BMI ≥35
Those younger than 60 years of age
Women with prior gestational diabetes
| A) | hepatic side effects. | ||
| B) | pulmonary side effects. | ||
| C) | cardiovascular side effects. | ||
| D) | gastrointestinal side effects. |
Another drug, acarbose, was found to reduce the progression of IGT to type 2 diabetes by 25% over 3.3 years in one study [109]. Because this medication can cause significant gastrointestinal side effects, many subjects discontinued the study medication [105]. This raises questions about the efficacy and practicality of using acarbose to prevent type 2 diabetes in actual clinical practice [109].
| A) | 24% | ||
| B) | 53% | ||
| C) | 73% | ||
| D) | 99% |
Reviews and meta-analyses of publications concerning metabolic surgery have consistently found improvement or resolution of diabetes in the majority of patients. A 2010 study demonstrated that gastric banding surgery could induce a remission of existing type 2 diabetes, with 73% of the study group returning to normal glycemia. Another study indicated that gastric banding induced prolonged satiety and resulted in improved glycemic control. Of those who did not achieve euglycemia, glycemic control was improved [109]. This suggests that surgical intervention may be an appropriate approach for preventing diabetes in select patients who are unable to lose weight by other means. The ADA recommends metabolic surgery as an option to treat type 2 diabetes in screened surgical candidates with a BMI of 40 or greater (37.5 or greater in Asian Americans) and in adults with a BMI of 35.0–39.0 (32.5–37.4 in Asian Americans) who have type 2 diabetes and who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods [13]. Metabolic surgery may be considered as an option for adults with diabetes and BMI 30.0–34.9 (27.5–32.4 in Asian Americans) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with tested efficacious nonsurgical methods [13]. After metabolic surgery, patients must receive ongoing lifestyle support and monitoring of micronutrient and nutritional status [13].
| A) | not to screen children for prediabetes. | ||
| B) | to screen for prediabetes in children with body mass indices greater than 30. | ||
| C) | to consider screening for prediabetes in children born to mothers with gestational diabetes. | ||
| D) | to perform risk-based screening for prediabetes and/or type 2 diabetes after the onset of puberty or after 10 years of age, whichever occurs earlier, in children and adolescents with overweight or obesity. |
More research is necessary to determine how to address prediabetes in children. It is unknown whether children with prediabetes have the same degree of risk for developing type 2 diabetes as adults with prediabetes, or if the predictors for long-term risks of diabetes are the same for children [119,120]. The ADA recommends that risk-based screening for prediabetes and/or type 2 diabetes be considered after the onset of puberty or after 10 years of age, whichever occurs earlier, in children and adolescents with overweight (BMI 85th percentile or greater) or obesity (BMI 95th percentile or greater) and who have one or more of the following risk factors for diabetes [13]:
Maternal history of diabetes or gestational diabetes during the child's gestation
Family history of type 2 diabetes in first- or second-degree relative
Race/ethnicity (e.g., Native American, African American, Latino, Asian American, Pacific Islander)
Signs of insulin resistance or conditions associated with insulin resistance (i.e., acanthosis nigricans, hypertension, dyslipidemia, PCOS, or small-for-gestational-age birth weight)
| A) | 15 to 20 minutes of physical activity every day. | ||
| B) | 30 minutes of physical activity on most days. | ||
| C) | 60 minutes of physical activity every day. | ||
| D) | 120 minutes of physical activity every week. |
The CDC recommends that children and adolescents participate in at least 60 minutes of physical activity every day [122]. A study presented at the 2010 ADA annual meeting revealed that obese boys who engaged in aerobic and resistance exercise decreased their total body fat, visceral fat, and insulin resistance, even without any changes in diet [123]. The study also indicated that resistance exercise training is appealing to boys and that it expends similar energy to aerobic training in this population.
| A) | Assign children to active chores. | ||
| B) | Have children walk or ride their bikes to school when possible. | ||
| C) | Have active family outings, such as walks, ball games, and swimming. | ||
| D) | Limit television, computer, or video game time to no more than four hours per day. |
Tips for the family working to become more active include:
Limit television, computer, or game "screen time" to less than two hours per day.
Assign children to active chores, such as raking leaves or carrying grocery bags.
Have children walk or ride their bikes to school when possible.
Have active family outings, such as walks, ball games, and swimming.
Encourage sports. If the child is not competitive, look for team activities that focus on fun and participation rather than winning.
Parents can be good roles models by being active themselves.
| A) | 10% more likely than non-Hispanic White adults to be diagnosed with diabetes. | ||
| B) | 30% more likely than non-Hispanic White adults to be diagnosed with diabetes. | ||
| C) | 45% more likely than non-Hispanic White adults to be diagnosed with diabetes. | ||
| D) | 70% more likely than non-Hispanic White adults to be diagnosed with diabetes. |
Diabetes is an urgent issue in the Latin American/Hispanic communities. Hispanic adults are 70% more likely than non-Hispanic White adults to be diagnosed with diabetes [131]. Rates of complications of diabetes are also higher among this group. Abdominal obesity and insulin resistance greatly increase the risk for metabolic syndrome in this population.
| A) | Cabbage | ||
| B) | Pineapple | ||
| C) | Butter beans | ||
| D) | Turnip greens |
The traditional Hispanic diet is high in fruits, vegetables, and fiber, and low in fat. However, acculturation to the American diet has changed traditional preferences and practices to a less healthy style of eating. Healthy choices most likely to appeal to this population include [128]:
Vegetables: Cabbage, carrots, cassava, jicama, nopales, peppers, tomatoes (salsa)
Fruits: Açaí, agave, banana, cherimoya, guava, mango, passion fruit, starfruit
Grain/starch: Amaranth, bread, corn, pasta, quinoa, rice, tortilla
Legumes, nuts, seeds: Pine nuts, black, garbanzo, kidney, and pinto beans
Protein: Abalone, crab, sea bass, cod, chicken, eggs, beef, pork
Dairy: Asadero cheese, yogurt, milk
| A) | Obesity | ||
| B) | Hypertension | ||
| C) | Sedentary lifestyle | ||
| D) | All of the above |
African Americans have a high prevalence of cardiovascular risk factors that may be reduced with lifestyle modification. These include obesity, hypertension, sedentary lifestyle, and tobacco use [127]. Unfortunately, studies have indicated that African Americans are less likely to participate in health screening programs. This is due in part to poor access, but may also stem from cultural and historical factors, such as mistrust of the healthcare system stemming from a history of inequitable treatment [127].
| A) | they tend to have much lower body fat percentages. | ||
| B) | central adiposity is the only reliable predictive factor. | ||
| C) | they tend to develop insulin resistance and type 2 diabetes at much lower indices. | ||
| D) | they tend to develop insulin resistance and type 2 diabetes at much higher indices. |
The incidence of diabetes among Asian Americans has increased more rapidly among those who have lived in the United States for a longer period of time than among new immigrants or those living in Asia [127]. Japanese individuals living in Seattle have diabetes prevalence four to five times that of those living in Tokyo [127]. Use of BMI is not as reliable a tool for predicting diabetes risk in Asian populations, as they tend to develop insulin resistance and type 2 diabetes at much lower indices [13,135]. The International Diabetes Federation has determined lower measures of waist circumference for determining health risk in Asian populations [135]. A systematic review of dietary self-management of diabetes among Asian Americans identified themes, including cultural beliefs about food, that characterize the cultural perspectives and experiences that influence diabetes self-management [136]. Patients reported receiving dietary recommendations that did not align with their beliefs about food as medicine and a source of balance in life and that recommendations to remove refined carbohydrates (e.g., rice) from their diets caused them to feel isolated from familiar and shared food habits and practices [136].
| A) | self-efficacy. | ||
| B) | cues to action. | ||
| C) | perceived barriers. | ||
| D) | perceived susceptibility. |
Perceived susceptibility is the first construct of the HBM. This may be reflected by the patient considering "What is the likelihood that I will get diabetes?" Patients who believe the risk is low will be less likely to make changes to prevent diabetes. Educating patients about the risk factors for diabetes will help them understand their susceptibility.
| A) | Agree on patient goals. | ||
| B) | Advise patient about what to change. | ||
| C) | Analyze effectiveness of interventions. | ||
| D) | Assess current practices, barriers, and readiness to change. |
The U.S. Preventive Services Task Force has developed the Five A's protocol, a widely used framework for supporting behavior change in clinical settings [147]. The Five A's protocol can help structure an approach to help patients make health behavior changes. The Five A's are [147]:
Assess current practices, barriers, and readiness to change.
Advise patient about what to change.
Agree on patient goals (negotiate).
Assist with change strategies and overcoming barriers.
Arrange for resources and referral, follow-up, and support.
| A) | precontemplation stage. | ||
| B) | contemplation stage. | ||
| C) | preparation stage. | ||
| D) | action stage. |
The contemplation stage begins when a patient becomes less resistant to the idea of behavior change. However, he or she remains acutely ambivalent about change and continues to procrastinate. At this time, the person acknowledges the need for change but is held back by his or her reasons for staying the same. A typical contemplative statement would be, "I would really like to exercise, but I just don't have the time." Although the prospect of change within the next six months is characteristic of this stage, people can remain in contemplation for an extended period of time. Patients may be assisted through this stage by promoting their self-efficacy and supporting their efforts to gather information. Specific interventions include reflective listening, providing empathic feedback, and offering information and resources as appropriate. Motivational interviewing, to be discussed in more detail later, is a powerful method for helping precontemplative and contemplative people move further along in the process of change.
| A) | Healthy eating behaviors | ||
| B) | Assessing readiness to change | ||
| C) | Identifying nonmodifiable risk factors | ||
| D) | Overcoming barriers to lifestyle change |
Topics included in diabetes prevention programs include [72,162]:
Definition of prediabetes
Health risks associated with prediabetes
Identifying modifiable risk factors
Lifestyle interventions to prevent progression to type 2 diabetes
Significance of cardiovascular health and risk reduction
Healthy eating behaviors
Exercise recommendation
Weight-loss strategies
Assessing readiness to change
Overcoming barriers to lifestyle change
Goal setting and action planning
Medical follow up to monitor blood glucose, lipids, weight, and blood pressure
Signs and symptoms of hyperglycemia and when to call a healthcare provider