SAN FRANCISCO — Take time to read the updates of guidelines for the management of prediabetes or diabetes carefully, because little pearls can be buried in the text, Dr. Richard M. Bergenstal said at a meeting sponsored by the American Diabetes Association.
He says he has noticed a shift, for example, in nutrition recommendations for the prevention of diabetes in the latest update of the American Diabetes Association's major position statement, “Standards of Medical Care in Diabetes,” which states that for weight loss, “either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to 1 year)” (Diabetes Care 2008;31:S1-S108).
“This is a huge change,” said Dr. Bergenstal, executive director of the International Diabetes Center, Minneapolis. “We've always just said it's got to be low-fat calorie-restricted diets.”
The new recommendation is more patient centered and gives providers more leeway to figure out what patients might be willing to do to change their diets and to match the pros and cons of different diets to individual patients.
“For the first year, let people do what they're going to do to lose some weight,” he paraphrased. “I thought that was an interesting and significant change, but it just shows up as a little bullet in the standards of care, so read them carefully.”
The updated guidelines state that for patients with prediabetes, counseling for lifestyle modifications is the standard of care for patients with either impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). The goal should be a weight loss of 5%–10% and an increase in physical activity to at least 150 minutes a week of moderate activity such as walking. Follow-up counseling is recommended.
In addition to lifestyle counseling, treatment with metformin may be considered for people at very high risk of developing diabetes: those who are obese, are younger than 60 years old, and have both IFG and IGT plus other risk factors for diabetes (such as a family history of the disease). Patients with prediabetes should be monitored yearly for the development of diabetes.
The guidelines eschewed the use of thiazolidinediones or incretin mimetics in these patients because more data are needed about the risks and benefits of these agents for preventing diabetes, Dr. Bergenstal noted.
In recent studies, other suggested therapies for prediabetes have included walking; combining aerobic exercise and weight lifting; getting adequate sleep; surgery; monitoring caffeine intake and diet; and medications.
Dr. Bergenstal is an advisor to or has received research funding from multiple companies that make medications or devices for diabetes.