Management of prediabetes to prevent diabetes among Indians: Expert consensus

Among Asian Indians, prediabetes cases are rapidly converted to diabetes. Also, prediabetes predisposes the development of macrovascular and microvascular complications (to a lesser extent) of diabetes. The ICMR-INDIAB (Indian Council of Medical Research–India Diabetes), in a large community-based epidemiological study, reported an overall prediabetes prevalence to be 10.3%, derived from 15 Indian states. Prediabetes, instead of being considered a path to diabetes, should be seen as an opportunity for diabetes prevention. Thus, early prediabetes screening, treatment, and detection should be a national priority.

The consensus statement outlined the approaches to screening and pharmacological and lifestyle management of prediabetes in Asian Indians. Many countries have introduced lifestyle programs for diabetes prevention and, when indicated, pharmacological intervention with metformin. The consensus on early detection and management will help reduce prediabetes progression to diabetes and associated complications. It will also help raise awareness for screening and risk stratification of people with prediabetes which may guide physicians in understanding potential interventions.

Recommendations for Type 2 Diabetes Prevention in Individuals with Prediabetes

• The authors recommend 6–8 hours of daily sleep.
• The authors recommend losing 5–10% of body weight for overweight or obese individuals, maintaining the ideal body weight right from pregnancy, and counting and watching calories.
• The authors recommend limiting the intake of juices, refined food grains, and trans fat. Also, saturated fats and simple sugars should be limited.
• An ample quantity of fibre is included in all meals.
• The authors stress the importance of individualizing the per cent of calories from carbohydrates and fat based on clinical goals for each individual.
• The authors recommend swimming, brisk walking, cycling, dancing, or outdoor sports that can provide exercise to the body should be performed daily.
• Exercise for 30 minutes 5 days a week should be performed.
• Walking around generally at least five times every week is necessary to keep mobility.
• Along with exercise, yoga is a promising adjunct.
• The threshold for the action of pharmacological therapy should be based upon: - hyperglycemia's severity, self-perception of severity, susceptibility of a person like those people who are more susceptible to worsening dysglycemia, developing CV complications, developing diabetes, or having positive family history should be treated differently than less susceptible patients, support from the system like economic support to the patient.

Guideline Recommendations on Metformin Use in Diabetes Prevention

• Metformin therapy for type 2 diabetes (T2D) prevention should be considered in those with prediabetes, with BMI >35 kg/m2, age 60 years, and women with prior gestational diabetes.
• Metformin may reduce T2D risk in subjects with impaired glucose tolerance (IGT).
• In cases where lifestyle intervention is insufficiently effective for body weight reduction and improving glucose tolerance, metformin should be used 250–850 mg/day.

Other key takeaways from the consensus

• People with prediabetes clinical risk factors can be screened using the Indian Diabetes Risk Score (IDRS) screening tool.
• The risk for macrovascular disease starts at prediabetes as it increases CVD events, stroke, myocardial infarction, and CV death risk.
• Biomarkers help identify people with a high risk of developing diabetes.
• Prediabetes has also been linked with retinopathy, neuropathy, and nephropathy.
• It is mandatory to identify and aggressively treat prediabetes.
• Biomarkers help identify people with a high risk of diabetes development.
• Lifestyle intervention is critical to the management of prediabetes.
• Large, randomized clinical trials have shown that metformin prevents diabetes, particularly in younger and obese patients.
• Metformin is the only pharmacologic agent recommended for preventing or postponing T2D.

"In the Indian population, there has been an alarming increase in prediabetes cases. Thus, the time seemed right for developing a proactive approach to prediabetes," Ashok Kumar Das and the research team wrote. "Considering this, we developed a consensus on risk factors, prevalence, interventions and biomarkers for prediabetes."

Reference:

Das AK, Mohan V, Ramachandran A, et al. An Expert Group Consensus Statement on "Approach and Management of Prediabetes in India". J Assoc Physicians India 2022;70(12):69–78.