By Brian Nambale , What you need to know

In pre-diabetes (impaired glucose tolerance), your blood sugar (glucose) is raised beyond the normal range. Whilst this raised glucose level is
not so high that you have type 2 diabetes, you are at increased risk of
developing type 2 diabetes when you have pre-diabetes.

What is Pre Diabetes?

If you have pre-diabetes (impaired glucose tolerance), your blood sugar (glucose) is raised beyond the normal range but it is not so high
that you have diabetes. However, if you have pre-diabetes you are at
risk of developing type 2 diabetes.

Between 1 and 3 out of every 4 people with pre-diabetes will develop diabetes within ten years.

It is also thought that having pre-diabetes increases your risk of
developing conditions such as heart disease, peripheral arterial disease
and stroke (cardiovascular diseases). Also, people who have
pre-diabetes are more likely also to have other risk factors for
cardiovascular disease, including high blood pressure, raised
cholesterol levels, being overweight, etc. See the separate leaflets
called Cardiovascular Disease (Atheroma) and Cardiovascular Health Risk Assessment for more details.

The World Health Organization (WHO) defines someone as having pre-diabetes if they have:

• A fasting blood glucose of less than 7 mmol/L; and
• A blood glucose of 7.8 mmol/L or more but less than 11.1 mmol/L after a two-hour oral glucose tolerance test.

However, the glucose tolerance test is rarely used now. The most commonly used
test to identify pre-diabetes is now the HbA1c blood test. The WHO and
the National Institute for Health and Care Excellence (NICE) have
recommended that an HbA1c blood test level of 42-47 mmol/mol (6.0-6.4%)
indicates a high risk of diabetes.

What is impaired fasting glycaemia?

The WHO has also said that someone has impaired fasting glycaemia if they have:

• A fasting blood glucose between 6.1 to 6.9 mmol/L; and
• A blood glucose of less than 7.8 mmol/L after a two-hour oral glucose tolerance test.

NICE states that someone with a fasting blood glucose of 5.5-6.9 mmol/L is at high risk of developing type 2 diabetes.

If you have impaired fasting glycaemia, you are also thought to have an
increased risk of developing diabetes. Your risk of developing
cardiovascular disease is also increased but this seems to be lower than
if you have pre-diabetes (impaired glucose tolerance). The rest of this
leaflet is about pre-diabetes.

How common is pre-diabetes?

Many people have pre-diabetes (impaired glucose tolerance) and because there
are no symptoms, they do not know that they have it. Diabetes UK
estimates that around seven million people in the UK have pre-diabetes.

What causes pre-diabetes and who develops it?

Pre-diabetes (impaired glucose tolerance) develops for the same reasons as type 2
diabetes (see above). There are various things that can increase your
risk of developing pre-diabetes. They are the same risk factors as those
for type 2 diabetes. They include:

• Being overweight or obese (most people with pre-diabetes are overweight or obese).
• Having a family history of diabetes. This refers to a close family member with diabetes - a mother, father, brother or sister.
• Doing little physical activity.
• Having other risk factors for cardiovascular disease such as high blood pressure or high cholesterol levels.
• If a woman has polycystic ovary syndrome and is also overweight.
• If you developed diabetes during pregnancy (called gestational diabetes).

What are the symptoms of pre-diabetes and how is it diagnosed?

People with pre-diabetes (impaired glucose tolerance) usually have no
symptoms. You are often found to have pre-diabetes after blood tests
taken for another reason show that you have a raised blood sugar
(glucose) level. Sometimes, your doctor may suggest that a screening
blood test should be taken to check your blood glucose because they are
worried that you may have some risk factors for pre-diabetes or
diabetes. For example, if you have high cholesterol levels, are
overweight or have high blood pressure, or if you have had a heart
attack or stroke, your doctor may suggest that you have a blood test to
check your blood glucose.

Pre-diabetes is now most often diagnosed using a blood test called HbA1c.

An HbA1c value of 48 mmol/mol (6.5%) or above is recommended as the
blood level for diagnosing diabetes. People with an HbA1c level of 42-47
mmol/mol (6.0-6.4%) are often said to have pre-diabetes because they
are at increased risk of diabetes and cardiovascular disease.

Another test to diagnose pre-diabetes is the glucose tolerance test but this is much less often used now.

How is pre-diabetes treated?

There is increasing evidence that if pre-diabetes (impaired glucose
tolerance) is treated, the progression to diabetes can be prevented.
Also, it may be possible to prevent cardiovascular disease from
developing. So, it is important to know if you have pre-diabetes and to
treat it in order to reduce your risk of developing diabetes and
cardiovascular disease. Treatments that have been suggested include
lifestyle changes and treatments with medicines.

It is also very important to have a regular blood test to recheck your blood sugar
(glucose) level in case you develop diabetes. The frequency of the blood
test will vary but you should discuss this with your doctor. A blood
glucose test at least once each year is usually recommended.

Referral for help and support

The signs of drinking too much and urinating so much so be the first clue to take you to a near by recognized and trained healthcare professionals.

If you are diagnosed with pre-diabetes and live in Uganda in Eastern Uganda especially Mbale District, Medicure Trauma Centre will offer you referral to this
service. It involves at least 13 sessions over about 9 months, each
lasting 1-2 hours. You will be supported to set and achieve goals and
make positive changes to reduce your risk of developing type 2 diabetes.
Most of the sessions will be run as face-to-face groups with other
people who also have pre-diabetes and led by one or more experts.

Lifestyle changes

Lifestyle changes have been found to be the most effective way to stop
pre-diabetes from developing into diabetes. Losing weight if you are
overweight, and increasing your levels of physical activity, can help to
reduce insulin resistance and therefore make the insulin that is
produced more effective at controlling your blood glucose levels.

If you have pre-diabetes, you should:

• Eat a healthy balanced diet. Your practice nurse and/or a dietician will give details on how to eat a
  healthy diet. The diet is the same as recommended for everyone. The
  idea that you need special foods if you have pre-diabetes or diabetes is
  a myth. Basically, you should aim to eat a diet low in fat, high in
  fibre and with plenty of fruit and vegetables:
• Starchy foods contain carbohydrates. Standard advice is that you should continue to
  eat some starchy foods, although you should focus on wholegrain and
  wholewheat versions - so-called 'complex carbohydrates'. These tend to
  have a lower glycaemic index (GI) which means they are more slowly
  absorbed and do not raise your blood sugar as rapidly.
• However, what many people don't realise is that starchy carbs like bread,
  potatoes or breakfast cereals digest down into a surprisingly large
  amount of sugar. More and more people are discovering that by reducing
  the carbs (both sugary and starchy) in their diet, it is possible to
  lose weight and reduce blood sugar (glucose). If you do include carbs in
  your diet, choose complex carbs.
• Lose weight if you are overweight. Getting to a perfect weight is unrealistic for many people. However, if
  you are overweight or obese then losing some weight will help to reduce
  your blood glucose level (and have other health benefits too).
• Do some physical activity regularly. If you are able, a minimum of 30 minutes of physical activity at least
  five times a week is advised. For example, walking, swimming, cycling,
  jogging, dancing - anything that makes you at least mildly out of breath
  and mildly sweaty. You can start slowly and build up. You can also
  spread the activity over the day - for example, two 15-minute spells per
  day. Regular physical activity also reduces your risk of having a heart
  attack or stroke. Always check with your doctor that it is safe to
  start exercising if you have been inactive for a long period.

There are also other lifestyle changes that you can make to reduce your cardiovascular disease risk. These include:

• Stopping smoking if you are a smoker.
• Ensuring that you stick to the recommended alcohol intake. See the separate leaflet called Alcohol and Sensible Drinking for more details.

Make sure that your blood pressure stays within the normal range. Have your
blood pressure checked regularly with your practice nurse.

Also, discuss with your doctor or practice nurse if you need a cholesterol
check and/or treatment to lower your cholesterol level.

Treatments with medicines

A number of medical trials have looked at the use of various treatments
with medicines for people with pre-diabetes to see if they can help to
prevent diabetes and cardiovascular disease. Medicines that have been
trialled include metformin, acarbose, a group of medicines called angiotensin-converting enzyme (ACE) inhibitors and another group of medicines called angiotensin-II receptor antagonists (also known as angiotensin receptor blockers).

Lifestyle changes (as indicated above) are the most important thing if you are
found to have pre-diabetes. However, the National Institute for Health
and Care Excellence (NICE) has recommended that metformin should be used
if a lifestyle-change programme isn't successful or isn't possible
because of a disability or medical reasons. A medicine called orlistat may also be recommended to help lose weight and therefore reduce the risk of developing diabetes.

What follow-up is needed if you have pre-diabetes?

If you are found to have pre-diabetes (impaired glucose tolerance), it is
important that you be followed up regularly by your doctor. This will
usually mean a blood test to check your fasting blood sugar (glucose)
level at least once a year. This is to make sure that you have not
developed diabetes. Your doctor is also likely to keep a check on any
other risk factors that you may have for cardiovascular disease. So,
they may monitor your weight and your blood pressure and also suggest a
blood test to check your cholesterol and triglyceride levels.

In the meantime, if you develop any symptoms of diabetes, you should visit
your doctor sooner. Symptoms include excess thirst, passing large
amounts of urine, tiredness, weight loss and feeling generally unwell.
Symptoms tend to develop quite slowly, over weeks or months.

Can pre-diabetes be prevented?

The same things that can help prevent type 2 diabetes can help prevent pre-diabetes (impaired glucose tolerance). These include:

• Eating a healthy balanced diet.
• Losing weight if you are overweight.
• Doing some physical activity regularly.

If you do develop type 2 diabetes, it's important to go for regular check-ups to ensure it doesn't worsen.